response essay of roughly 250-500 words

profileMedicalethics2017
bioethics--594-677-1.pdf.pdf_response_4.pdf

m _

.

C h

a p

te r I0

: E u

th a

n a

s la

a rid

P h

y s J c la

n o

A s s ls

te d

ÿ u

m ld

e 5

9 5

E uthanasia and P

hysician-A ssisted S

uicide

N o

o n

e e

sca p

e s d

e a

th --o

r th e

e th

ica l issu

e s th

a t

c o

m e

w ith

it A d

v a

n c e

s in

m e

d ic

in e

n o

w ra

is e

th e o

ld life

-a n d -d

e a th

q u e stio

n s a

n e w

, fo rce

n e w

o n

e s m

o re

u n

se tth

n g

, a n

d p

ro vo

ke a

n sw

e rs th

a t

a re

d is

tu rb

in g e

v e n w

h e n p

la u s ib

le . In

e u th

a n a -

sia a

n d p

h ysicia

n -a

ssiste d su

icid e , th

e b

io e th

lca l

heart of the m atter is the m

oral rightness of kill- ing or letting die for the good of the patient. T

he countless disputes on this terrain are often fierce a

n d

e le

m e

n ta

l, fo r th

e y a

re th

e visib

le sig

n s o

f d e e p co

n flicts a

m o n g fu

n d a m

e n ta

l m o ra

l p rin

- cip

le s a

n d p

e rsp

e ctive

s. D o cto

ls a n d n

u rse

s h a ve

s w

o rn

to p

re s e rv

e life

a n d re

lie v e s

u ffe

rin g --b

u t

h o w

to d

o th

is w h e n th

e o

n ly w

a y to

e n d su

f- fe

rin g is to

e n d life

? T

h e y u

n d e rsta

n d th

e n

e e d

to re

sp e ct p

a tie

n t a

u to

n o m

y, th e rig

h t o

f se lf-

d e

te rm

in a

tio n

--b u

t w h

a t sh

o u

ld th

e y d

o w

h e

n th

e p

a tie

n t fle

e ly ch

o o se

s to fo

rg o a

ll th e ir b

e st

e ffo

rts a n

d to

e m

b ra

ce e

xtin ctio

n ?

O r if th

e te

r- m

in a l p

a tie

n t, in

c h in

g in

a g o n y to

w a rd

d e s tru

c -

tio n

, a sks th

e m

to cu

t sh o

rt h e

r to rm

e n

t b y ld

ll- in

g h

e r w

ith a

le th

a l in

je ctio

n ? O

r if sh e b

e g s

o n ly fo

r so m

e h

e lp

in d

yin g b

y h e r o

w n h

a n d ?

O r if she has never expressed a choice about such

m a

tte rs

a n

d h

a s s

lip p

e d

in to

p e

rm a

n e

n t u

n c o

n -

scio u sn

e ss, w

ith e rin

g in

p a in

to th

e in

e vita

b le

? In

su ch

ca se

s, w h a t d

o e s b

e n e fice

n ce

o r m

e rcy o

r re

sp e ct fo

r a u to

n o m

y o r re

g a rd

lo t th

e sa

n ctity

of life dem and?

M o

re s

o th

a n

m o

s t o

th e

r is s u

e s in

b io

e th

ic s ,

the m orality of euthanasia and physician-assisted

suicide is tangled w ith legal and policy debates.

T h e e

th ica

l q u e stio

n s a

re , o

f co u rse

, lo g ica

lly d istin

ct fro m

th e se

co n ce

rn s. Y

o u a

re n

o t n

e ce

s- sa

rily g u ilty o

f in co

n siste

n cy if yo

u th

in k so

m e

in sta

n ce

s o f p

h ysicia

n -a

ssiste d

su icid

e a

re m

o r-

a lly p

e rm

issib le

b u t b

e lie

ve th

e p

ra ctice

sh o u ld

n e ve

r b e le

g a lize

d b

e ca

u se

le g a liza

tio n m

ig h t

le a

d to

a b

u s e

s . O

r y o

u m

a y , w

ith o

u t c

o n

tra d

ic t-

ing yourself, favor legalization to protect patient a

u to

n o

m y b

u t a

rg u

e th

a t su

icid e

in a

n y fo

rm is

a lm

o st n

e ve

r m o

ra lly a

cce p ta

b le

. In th

e h

e a t o

f co

n tro

ve rsy, th

e se

d istin

ctio n

s o fte

n g

e t b

lu rre

d ,

a n d a

m a jo

r ta sk o

f g o o d m

o ra

l re a so

n in

g is to

keep the focus sharp. N

o w

h e re

w a s m

o ra

l re a so

n in

g a

n d co

n ce

p tu

a l

clarity needed m ore and used less than in the re-

ce n

t ca se

o fT

e rri S

ch la

vo . In

1 9

9 0

, w h

e n

sh e

w a

s 26, S

chlavo's heart stopped suddenly for reasons th

a t a

re still u

n cle

a r; b

y th e tim

e sh

e w

a s re

su sci-

tated, she had suffered catastrophic and irrevers- ib

le b

ra in

d a

m a

g e

S h

e w

a s le

ft in w

h a

t d o

cto rs

c a ll a

p e rs

is te

n t v

e g e

ta tiv

e s

ta te

--w a k e fu

l b u t

w ith

o u

t c o

n s c io

u s n

e s s o

r in te

n tio

n a

l b e

h a

v io

r a

n d

a lm

o s t n

o c

h a

n c e

o f s

ig n

ific a

n t im

p ro

v e

- m

e n

t. In th

is c

o n

d itio

n s

h e

w a

s s

u s ta

in e

d fo

r ye

a rs b

y fo o d a

n d w

a te

r in je

cte d in

to h

e r b

o d y

through tubes. T he question arose: W

ould T elrl

have w anted to be kept alive like this? W

ould she have chosen death over this perpetual dalkness? S

he could not answ er and had left no w

ritten ie- co

rd o

f h e r p

Ie fe

re n ce

s. H e r h

u sb

a n d , M

ich a e l

S chiavo, becam

e her legal guardian and claim ed

th a

t T e

rri h a

d o

n ce

to ld

h im

th a

t sh e

w o

u ld

ra th

e r d

ie th

a n b

e a

rtificia lly su

sta in

e d a

s sh e

eventually w as. H

e said he w anted to have T

erri's feeding tube rem

oved so she could die w ith dig-

n ity. T

e rri's p

a re

n ts w

o u ld

h a ve

n o n e o

f th is a

n d

insisted that efforts to keep her alive should con- tIn

u e b

e c a u s e s

h e c

o u ld

e v e n tu

a lly

re g a in

c o n -

sciousness. A cross the country people debated

th e m

o ra

l q u e stio

n s. W

o u ld

re m

o vin

g T

e rri's

feeding tube be m urder? W

ould allow ing her to

die be a perm issible act of m

ercy? A ll the w

hile,

the legal w ar betw

een M ichael S

chiavo and T er-

ri's p

a re

n ts

d ra

g g e d o

n , w

ith th

e fo

rm e r s

e e k in

g p e rm

is s io

n to

d is

c o n n e c t th

e fe

e d in

g tu

b e a

n d

the latter trying to thw art him

. T he essential legal

issue w as w

ho had the legal right to decide T erri

S chxavo's fate. T

he list of people w ho w

eighed in on both the legal and m

oral questions is long and d

ive rse

--P re

sid e

n t G

e o

rg e

W . B

u sh

, sta te

le g

isla -

to rs, m

e m

b e

rs o f th

e U

S . C

o n

g re

ss, b io

e th

icists, re

lig io

u s le

a d

e rs, p

ro -life

g ro

u p

s, th e

g o

ve rn

o r o

f F

lorida, disability rights organizations, and a vast a

s s o

rtm e

n t o

f m e

d ia

c o

m m

e n

ta to

rs T

im e

a fte

r tim

e, state and federal courts sided w ith M

ichael S

chiavo, and in the end a judge gave perm ission

to rem ove T

erri's feeding tube. T hirteen days af-

te r its re

m o va

l, o n M

a rch

3 1 , 2

0 0 5 , T

e rri S

ch la

vo w

a s d

e a d .

In so

m e

w a

ys th e

S ch

la vo

ca se

is u n

iq u

e , b

u t

s e v e ra

l o f its

m o re

d is

tu rb

in g fe

a tu

re s a

re n

o t.

M a

n y c

o m

p e

llin g

e n

d -o

f-life d

ra m

a s a

re b

e -

in g p

la ye

d o

u t rig

h t n

o w

b e h in

d clo

se d h

o sp

ita l

d o o rs

, a w

a y fro

m n

e w

s c

a m

e ra

s , th

e p

o s tu

rin g

o f p

o liticia

n s, a

n d

th e

g a

ze o

f u n

a ffe

cte d

p e

o -

p le

T h e n

e e d fo

r in fo

rm e d m

o ra

l re a so

n in

g to

co m

e to

te rm

s w ith

th e

h e

a rt-b

re a

kin g

re a

litie s

IS a

cu te

--a n d like

ly to g

ro w

.

594

A lm

o st a

ll o f th

e te

rm s u

se d

to d

iscu ss th

e m

o -

ra h

ty o f killin

g a

n d

le ttin

g d

ie a

re co

n tro

ve rsia

l to

s o

m e

d e

g re

e . E

v e

n th

e m

e a

n in

g o

f d e

a th

--a seem

ingly straightforw ard concept to m

ost peo- p le

-h a s b

e e n a

p o in

t o f d

isp u te

N e ve

rth e le

ss, so

m e h

e lp

fu l d

istin ctio

n s a

re p

o ssib

le . F

o r th

e sa

ke o

f cla rity (a

n d n

e u tra

lity), e u th

a n a sia

ca n

b e ch

a ra

cte rize

d a

s d ire

ctly o r in

d ire

ctly b rin

g -

in g a

b o u t th

e d

e a th

o f a

n o th

e r p

e rso

n fo

r th a t

person's sake ÿ T he term

derives from the G

reek w

ords m eaning "good death" and evokes the idea

th a t ca

u sin

g o

r co n trib

u tin

g to

so m

e o n e 's e

n d

m a

y b e

sto w

o n

th a

t p e

rso n

a g

o o

d . D

e a

th is u

su -

ally considered an evil, perhaps the greatest evil, b

u t m

a n

y th in

k it ca n

b e

a b

le ssin

g if it sp

a re

s s o

m e

o n

e fro

m a

s lo

w , h

o rrific

d y in

g o

r a h

o p

e -

le ss, ve

g e ta

tive sle

e p .

D E

C ID

IN G

L IF

E A

N D

D E

A T

H

M a n y p

h ilo

so p h e rs m

a in

ta in

th a t th

e re

a re

tw o

fo rm

s o

f e u

th a

n a

s ia

. A c tiv

e e

u th

a n

a s ia

is s a id

to in

v o lv

e p

e rfo

rm in

g a

n a

c tio

n th

a t d

i- re

c tly

c a u s e s s

o m

e o n e to

d ie

--w h a t m

o s t p

e o -

p le

th in

k o f a

s "m e

rcy killin g

;' G ivin

g a

p a

tie n

t a le

th a l in

je ctio

n to

e n d h

is su ffe

rin g , th

e n , is a

ca se

o f a

ctive e

u th

a n a sia

. P a ssive

e u th

a n a sia

is allow

ing som eone to die by not doing som

ething th

a t w

o u

ld p

ro lo

n g

life . It in

clu d

e s re

m o

vin g

a p

a tie

n t's fe

e d in

g tu

b e o

r ve n

td a to

r, fa ilin

g to

p e rfo

rm n

e c e s s a ry

s u rg

e ry

, a n d re

fra in

in g fro

m g

iv in

g h

fe -s

a v m

g a

n tib

io tic

s . T

h e

d is

tin c tio

n b

e -

tw e e n th

e tw

o is th

o u g h t to

b e e

sse n tia

lly th is:

A ctive euthanasia is kdhng, but passive euthana-

sia is letting die. T

o so

m e p

e o p le

, th is co

n ce

p tu

a l b

o rd

e r b

e -

tw e

e n

a c tiv

e a

n d

p a

s s iv

e e

u th

a n

a s ia

is c

ru c ia

l fo

r a sse

ssin g

th e

m o

ra h

ty o f e

u th

a n

a sia

. T h

e y

p o in

t o u t th

a t w

h e re

a s le

ttin g a

p a tie

n t d

ie is

som etim

es m orally perm

issible, deliberately and d

ire ctly kllh

n g

a p

a tie

n t is a

lw a

ys w ro

n g

. T h

e fo

rm e

r p ra

ctice is le

g a

l a n

d o

fficia lly e

n d

o rse

d by the m

edical profession; the latter is illegal and o fficia

lly co n d e m

n e d . T

h e A

m e rica

n M

e d ica

l A

ssociation sanctioned this dichotom y in a 1973

policy statem ent:

2 h

e in

te n

tio n

a l te

lm m

a tlo

n o

f th e

h fe

o f o

n e

h u

m a

n b

e in

g b

y a n

o th

e r--m

e rcy kd

lln g

--lS co

n tra

ry to th

a t fo

r w h m

h th

e m

e d ica

l p ro

fe ssm

n sta

n d s a

n d is co

n tra

ry to th

e p

o h cy o

f th e A

m e n -

can M edical A

ssocm tlon

, T he cessatm

n of the em ploym

ent of ex- h

a o

rd m

a ry m

e a

n s to

p ro

lo n

g th

e h

fe o

f th e

b o

d y

w hen there lS

Irrefutable ew dence that blologm

al death lS

lm m

m ent is the declsm

n of the patient and/or m

lm edm

te fam ily.2

F o

r m a

n y (in

clu d

in g

m o

st p h

ysicia n

s), p a

s- sive

e u

th a

n a

sia m

a y b

e m

o ra

l, b u

t a ctive

e u

th a

- n a s ia

is n

o t.

B u t n

o t e

ve ryo

n e th

in ks th

is a ctive

-p a ssive

distinction m akes sense. S

om e argue that there is

no m orally significant difference betw

een m erci-

fully killing a patient and m ercifully letting the

p a

tie n

t d ie

. In b

o th

s itu

a tio

n s th

e d

o c to

r c a

u s e

s th

e p

a tie

n t's d

e a

th --b

y e ith

e i in

te n

tio n

a lly d

o in

g

$ 9 6 P

A R

T 3

' liF E

A N

D D

E A

T H

s o m

e th

in g in

th e o

n e in

s ta

n c e o

r in te

n tio

n a lly

re fra

in in

g fro

m d

o in

g s

o m

e th

in g in

th e o

th e r.

T h u

s a n

a ct o

f e u

th a

n a

sia m

a y b

e m

o ra

lly rig h

t o

r w ro

n g

, b u

t th e

rig h

tn e

s s o

r w ro

n g

n e

s s d

o e

s not depend purely on this active-passive divide. M

o re

o v e

r In p

ra c tic

e , d

is tin

g u

is h

in g

e x a

m p

le s

o f a

c tiv

e a

n d p

a s s iv

e e

u th

a n a s ia

m a y n

o t b

e a

s e

a s y a

s s

o m

e th

in k . T

h e

u s u

a l v

ie w

is th

a t p

a s -

sive e

u th

a n a

sia ca

n so

m e

tim e s b

e p

e rfo

rm e

d b y d

isco n n e ctin

g a

d yin

g p

a tie

n t's fe

e d in

g tu

b e

a n

d ve

n tila

to r. B

u t th

is e ve

n t ca

n a

lso b

e se

e n

a s a

n in

sta n ce

o f p

e rfo

rm in

g a

n a

ctio n th

a t

d ire

c tly

c a u s e s s

o m

e o n e to

d ie

--th a t is

, a c tiv

e e u th

a n a sia

. If e

u th

a n

a sia

in so

m e

fo rm

is m o

ra lly p

e r-

m isslb

le , its p

e rm

issib ility m

u st b

e lin

ke d to

th e

p a tie

n t's co

n se

n t. T

h u s b

io e th

tclsts ta lk a

b o u t

e u

th a

n a

s ia

th a

t is v

o lu

n ta

ry , n

o n

v o

lu n

ta ry

, o r

in v o

lu n

ta ry

. V o

lu n

ta ry

e u

th a

n a

s ia

re fe

rs to

s itu

- a

tio n

s in w

h ich

co m

p e

te n

t p a

tie n

ts vo lu

n ta

rily re

q u

e s t o

r a g

re e

to e

u th

a n

a s ia

, c o

m m

u n

ic a

tin g

th e ir w

ish e s e

ith e r w

h ile

co m

p e te

n t o

r th ro

u g h

in stru

ctio n

s to b

e fo

llo w

e d

if th e

y b e

co m

e in

- co

m p e te

n t (if th

e y fa

ll in to

a p

e rsiste

n t ve

g -

etative state, for exam ple). P

atients can indicate w

hat is to be done in incom petence by form

ulat- in

g a

n a

d v a

n c e

d ire

c tiv

e --u

s u

a lly

a liv

in g

w ill o

r a

d o

cu m

e n

t d e

sig n

a tin

g a

su rro

g a

te , o

r p ro

xy, to a ct o

n th

e ir b

e h a lf. N

o n vo

lu n ta

ry e u th

a n a sia

is p

e rfo

rm e

d w

h e

n p

a tie

n ts a

re n

o t co

m p

e te

n t to

chose death for them selves and have not previ-

ously disclosed their preferences. (Incom petent

p a tie

n ts in

clu d e n

o t o

n ly in

ca p a cita

te d a

d u lts

b u t in

fa n ts a

n d sm

a ll ch

ild re

n a

s w e ll.) In

th e se

circu m

sta n

ce s, th

e p

a tie

n t's fa

m ily, p

h ysicia

n ,

or other officially designated persons decide for th

e p

a tie

n t. In

vo lu

n ta

ry e u th

a n a sia

is b rin

g in

g a

b o

u t so

m e

o n

e 's d

e a

th a

g a

in st h

e r w

ill o r w

ith -

o u t a

slÿn g fo

r h e r co

n se

n t w

h ile

sh e is co

m p e -

tent to decide. It is illegal and considered m orally

im p e rm

issib le

b y b

o th

th o se

w h o a

p p ro

ve a

n d

d is

a p p ro

v e o

f e u th

a n a s ia

. It is th

e re

fo re

g e n e r-

ally left out of m oral debates, except perhaps in

s lip

p e ry

-s lo

p e a

rg u m

e n ts

w a rn

in g th

a t v

o lu

n -

ta ry o

r n o

n vo

lu n

ta ry e

u th

a n

a sia

w ill in

e vita

b ly

b e

co m

e in

vo lu

n ta

ry.

C o m

b in

in g th

e te

rm s a

c tiv

e , p

a s s iv

e , v

o lu

n -

ta ry

, a n d n

o n v o lu

n ta

ry , w

e c

a n id

e n tify

fo u r

kinds of euthanasia that have been the m ain fo-

cu s in

b io

e th

ics:

1 A

c tiv

e v

o lu

n ta

ry --D

ire c tly

.c a u s in

g d

e a th

(m ercy M

lling) w ith the consent of the

p a

tie n

t 2

A c tiv

e n

o n

v o

lu n

ta ry

--D ire

c tly

c a

u s in

g d e a th

(m e rcy killin

g ) w

ith o u t th

e co

n se

n t

of the patient 3 . P

a s s iv

e v

o lu

n ta

ry --W

ith h o ld

in g o

r w

ith d

ra w

in g

life -su

sta in

in g

m e

a su

re s w

ith the consent of the patient

4 . P

a s s iv

e n

o n v o lu

n ta

ry --W

ith h o ld

x n g o

r w

ith d

ra w

in g

life -s

u s ta

in in

g m

e a

s u

re s

w ithout the consent of the patient

L e

g a

lly a n

d e

th ica

lly, th e

sta rke

st co n

tra st

a m

o n

g th

e se

is b e

tw e

e n

a ctive

a n

d p

a ssive

e u

th a

- n

a sia

. A ctive

e u

th a

n a

sia (w

h e

th e

r vo lu

n ta

ry o r

n o n vo

lu n ta

ry) is u n la

w fu

l, w h ile

p a ssive

e u th

a -

nasia (both voluntary and nonvoluntary) is legal p

ro vid

e d

ce rta

in co

n d

itio n

s a re

m e

t. Ju d

icia l

rulings have firm ly established a right of patients

to re

fu s e

tre a

tm e

n t--a

n d

th u

s to

h a

v e

life -

s u s ta

in in

g tre

a tm

e n t w

ith h e ld

o r w

ith d ra

w n --

e ve

n th

o u

g h

th e

p a

tie n

t d ie

s a s a

re su

lt. W ith

- d ra

w in

g o

r w ith

h o ld

in g tre

a tm

e n t fro

m a

n in

- com

petent patient is generally legal if the patient h a s le

ft In stru

ctio n s o

r if a n a

p p ro

p ria

te p

e rso

n ca

n b

e ch

o se

n to

m a ke

th e n

e ce

ssa ry d

e cisio

n s.

C o n te

m p o ra

ry m

o ra

l d e b a te

c e n te

rs m

o re

o n

a ctive

th a

n o

n p

a ssive

e u

th a

n a

sia . T

h e

re is co

n -

slderable agreem ent about the m

oral rightness of allow

ing a patient to die but intense controversy about the perm

lssibihty of deliberately causing a p a tie

n t's d

e a th

(b y a

d m

in iste

rin g a

le th

a l in

je c-

tion, for exam ple), w

hether the act is considered v o

lu n

ta ry

o r n

o n

v o

lu n

ta ry

. R

ecentl5 disputes over euthanasia have raged alongside argum

ents about physician-assisted su- icide, in w

hich a patient takes his ow n life w

ith the aid of a physician. In a typical scenario, a patient asks the physician for help in com

m itting suicide,

th e

p h ysm

ia n a

ssists th e p

a tie

n t b

y p re

scrib in

g le

th a l d

o se

s o f d

ru g s o

r e xp

la in

in g a

m e th

o d o

f

C h a p te

r 1 0 : E

u th

a n a s ia

a n d P

h y s ic

ia n -A

s s is

te d S

m c ld

e $

9 7

L E

G A

L B

R R

E F

E u th

a n a s ia

a n d A

s s is

te d S

u ic

id e :

M a

|o r D

e v e

lo p

m e

n ts

1990 In C ruzan v D

irector, M issour# D

epartm ent

o f H

e a lth

, th e U

.S S

u p re

m e C

o u rt re

co g n ize

s th

e rig

h t o

f p a

tm n

ts to re

fu se

tre a

tm e

n t

(essentially a "right to die") and finds co

n stitu

tio n a l lu

stifica tlo

n fo

r h yin

g w

d ls a

n d

su rro

g a

te s w

h o

m a

ke m

e d

m a

l d e

cisio n

s fo r

in c o m

p e te

n t p

a tm

n ts

.

1 9 9 4 O

re g o n p

a sse

s th e D

e a th

W ith

D Ig

m ty A

ct, legahzing the use of physician-assisted sure,de u n d e r sp

e cific co

n d itio

n s It p

e rm

its d o cto

rs to prescribe drugs that term

inally ÿ11 patients c a

n u

s e

to c

o m

m it s

m c id

e .

1997 In separate cases--W ashington v G

lucksberg and V

acco v. Q uill--the S

uprem e C

ourt rules th

a t th

e re

is n o co

n stitu

tio n a l rig

h t to

physician-assisted sm clde but notes that each

sta te

m a

y e sta

b b

sh its o

w n

p o

b cy o

n th

e

issue. It exphcJtly acknow ledges a dlstm

cnon betw

een assisted sm cide and the w

ithdraw al

o f life

-su sta

in in

g tre

a tm

e n

t 2 0 0 1 U

.S A

tto rn

e y G

e n e ra

l Jo h n A

sh cro

ft ru e s

to th

w a

rt th e

O re

g o

n rig

h t-to

-d ie

la w

b y

a u th

o rszin

g th

e D

ru g E

n fo

rce m

e n t A

g e n cy to

, act against physicians prescribing drugs for a ssiste

d su

m Jd

e .

2006 T he S

uprem e C

ourt rules that the Jum ce

D epartm

ent (headed by A shcroft and later

A lberto G

onzales) had no authority to interfere w

ÿth physm ÿans acting under the O

regon law .

2 0

0 8

T h

ro u

g h

a re

fe re

n d

u m

vo te

, W a

sh in

g to

n becom

es the second state to legahze physm

lan-asslsted sum ide

2 0

0 8

A d

istrict co u

rt ru h

n g

m th

e ca

se o

f B a

xte r

v S tate of M

ontana asserts that M ontana

residents have a right to physm lan-asslsted

sm cide, thereby legalizing the pracnce m

a th

w d

sta te

. In 2

0 0

9 th

e M

o n

ta n

a S

u p

re m

e C

o u

rt a ffirm

e d

th e

e a

rh e

r co u

rt ru h

n g

s u ic

id e , a

n d th

e p

a tie

n t--n

o t th

e p

h y s ic

ia n --p

e r-

form s the final act that causes death. In contrast,

in active euthanasia the physician perform s the

final act. M any argue that this difference in the ul-

tim ate cause of death im

plies a difference in m oral

responsibihty. In physician-assisted suicide, the patient is thought to bear ultim

ate m oral respon-

sib ih

ty fo r th

e ta

lcin g o

f life . O

th e rs d

o u b t th

a t

a n

y d istin

ctio n

in u

ltim a

te ca

u se

s ca n

a m

o u

n t to

a m oral difference. T

hus they contend that physi- cia

n -a

ssiste d

su icid

e a

n d

a ctive

vo lu

n ta

ry e u

th a

- n

a sia

a re

m o

ra lly e

q u

iva le

n t. W

h a

t is th e

m o

ra l

difference, they ask, betw een a physician helping

a p

a tie

n t d

ie b

y (1 ) a

d m

in iste

rin g

a le

th a

l in je

c- tion upon request or (2) prescribing a lethal dose of m

edications upon request? T

h e

A m

e rica

n M

e d

ica l A

sso cia

tio n

h a

s d e

- n o u n ce

d p

h ysicia

n -a

ssiste d su

icid e a

s u n e th

ica l

and inconsistent w ith physicians' duty to prom

ote

h e a h n g a

n d p

re se

rve life

. S u rve

ys su g g e st, h

o w

- ever, that m

any doctors support the use of physi- cian-assisted suicide, and up to half of adults be- lieve it should be legal in cases of term

inal illness o r in

cu ra

b le

d ise

a se

w ith

se ve

re p

a in

. T o d

a te

, it is legal only In O

regon, W ashington, and M

ontana. T

he U .S

. S uprem

e C ourt has ruled that states m

ay legalize or prohibit it as they see fit.

P art of the difficulty of m

aking everyday m oral

decisions about end-ofqife situations is that death itself is not so easy to define. T

raditionally death w

a s u

n d

e rsto

o d

to o

ccu r w

h e

n b

re a

th in

g a

n d

h e a rtb

e a t c

e a s e d . A

p e rs

o n w

h o w

a s n 't b

re a th

- ang and had no heartbeat w

as dead. B ut thanks to

m o d e rn

m e d icin

e , m

a ch

in e s ca

n m

a in

ta in

so m

e -

one's breathing and heartbeat indefinitely--even though there IS

perm anent loss of all brain func-

tion. H eart and lungs keep going, but the individ-

ual IS irreversibly brain-dead and can rem

ain that

598 P A

R T

3' LIF E

A bed D

F A

T H

in 2

0 0 0 a

la rg

e su

rve y o

f o n e o lo

g lsts re

ve a le

d th

a t.

• 2 2 .5

% su

p p o rte

d th

e u

se o

f p h ysicia

n -

a ssiste

d su

icid e

fo r a

te rm

in a

lly ill p a

u e

n t

w ith

"u n re

m ittin

g p

a in

", 6 .5

% fa

v o re

d a

c tiv

e

e u

th a

n a

sia In

th e

se circu

m sta

n ce

s • 5

6 .2

% h

a d re

ce fve

d re

q u e sts fro

m p

a tie

n ts

fo r p

h y s m

la n -a

s s ls

te d s

u ic

id e , 3

8 .2

% , fo

r a c n v e

e u

th a

n a

sia .

• 10.8% had perform

ed physm lan-asslsted

sm cld

e ; 3

.7 %

, a ctive

e u

th a

n a

sia

E zekiel J E

m anuel, D

iane F atrclough, B

rian C larndge, et al,

"A ttitudes and P

racuces of U S

O ncologlsts R

egarding E

u th

a n a sia

a n d P

h ysm

la n -A

sslste d S

u icid

e ," A

n n a ls o

f In te

rn a l

M e&

cm e 133 7 (3 O

ctober 2000), 527-32

w ay for decades. B

y the traditional standard, the in

d ivid

u a l is a

live , b

u t th

is se e m

s co u n te

rin tu

itive .

W e

se e

m to

n e

e d

a n

e w

co n

ce p

t o f d

e a

th --a

n im

p o

rta n

t co n

sid e

l a tio

n sin

ce a

n y n

o tio

n w

e a

d o

p t

w ould dram

atically influence our judgm ents about

m orally perm

issible behavior tow ard the living and

the dead. If w e judge an individual to be dead, then

w e w

ould presum ably think her no longer a person.

If she is no longer a person, then it w ould seem

to be perm

issible to & sconnect all life support, hai vest

oigans from the body foI transplant, or prepare the

body for burial. B ut if, despite appearances, she is

still a person, w oulddt doing any of these things be

m urder? If so, those w

ho perform these acts w

ould be m

orally and legally culpable. In

1 9

6 8

a c

o m

m itte

e a

t H a

rv a

rd M

e &

c a

l S

chool form ulated a new

w ay of conceiving death,

a peispective that has since becom e the standard

in le

g a l a

n d m

e d

ica l m

a tte

rs A cco

rd in

g to

th is

w h

o le

b ÿa

in vie

w o

f d e

a th

, a n

in d

ivid u

a l sh

o u

ld be judged dead w

hen all brain functions perm a-

nently cease B rain death m

eans genuine death. B

ut several experts take issue w ith this view

. T hey

point out that som e physiological processes such

a s re

sp ira

tio n a

re p

a rtly in

d e p e n d e n t o

f b ra

in fu

n ctio

n s, a

n d

in d

ivid u

a ls th

a t m

a n

y w o

u ld

re -

gard as dead (those in persistent vegetative states, for exam

ple) m ay have som

e residual brain activ- ity. B

y th e w

h o le

b ra

in sta

n d a rd

, T e

rn S

ch la

vo ,

b e

in g

w a

ke fu

l b u

t la ctn

n g

co n

scio u

sn e

ss, w a

s a live

u n til a

ll b ra

in a

ctivity sto p p e d . T

o so

m e ,

th is co

n se

q u e n ce

m a ke

s se n se

; to o

th e rs, it se

e m

s

odd. A better notion of death, som

e aigue, is the h @

e r b

ra in

vw w

, w h ich

sa ys th

a t a

n in

d ivid

u a l

should be considered dead w hen the higher brain

o p e ra

tio n s re

s p o n s ib

le fo

r c o n s c io

u s n e s s p

e r-

m a n e n tly sh

u t d

o w

n 2

h e th

o u g h t b

e h in

d th

is standard is that individuals are dead w

hen they are no longer persons, regardless of w

hat physi- o

lo g

ica l a

ctivity p e

rsists, a n

d in

d ivid

u a

ls a re

n o

lo n g e r p

e rso

n s w

h e n co

n scio

u sn

e ss p

e rm

a n e n tly

te rm

in a te

s. B y th

e h

ig h e r b

ra in

crite rio

n , T

e rri

S ch

ia vo

d ie

d w

h e n h

e r h

ig h e r b

la in

fu n ctio

n s

p e

rm a

n e

n tly sto

p p

e d

, e ve

n th

o u

g h

o th

e r b

ra in

a ctivity co

n tin

u e

d fo

r ye a

rs A g

a in

, so m

e w

o u

ld find this judgm

ent plausible; others, bizarre

P eople have an interest m

m aM

ng im poltant decl-

stu n

s a b

o u

t th e

n h

ve s m

a cco

rd a

n ce

w ith

th e

n o

w n

conceptm n of how

they w ant then lives to go. In

e x e

lc ls

ln g

a u

to n

o m

y o

i s d

f-d e

te im

in a

tm n

, p e

o p

le

take J esponslbfilty foi their lives; since dying is a pal t of life, chom

es about the m annel of then dying

and the tim ing of the11 death m

e, fol m aw

people, paIt of w

hat is involved m taM

ng lesponsibfiW for

theu lives. M any people ale concerned about w

hat the last phase of then hves w

ill be hke, not m erely

because of feais that then dying m ight involve

them in great suffeiing, but also because of the

desire to letam dignity and as ranch contIol over

then lives as possible during this phase.. T here

is no single, objectively corIect answ er as to w

hen, if at all, life becom

es a buiden and unw anted B

ut that sim

ply points up the lm poI tance of individuals

being able to decide autonom ously foi them

selves w

h e

th e

i th e

li o w

n live

s ie ta

in su

fficie n

t q u

a lity a

n d

dignity to m ake hfe w

oith hvIng.3

has alw ays been the stiongest agum

ent fo] eutha- nasm

m those cases to w

hm h it applies?

L e t u

s e xa

m m

e th

e tw

o m

a in

fla sh

p o in

ts in e

n d -

of-life bloethics: active voluntary euthanasia and p

h ysicia

n -a

ssiste d

su icid

e . W

e ca

n fo

cu s m

o stly

o n th

e fo

rm e r sin

ce a

rg u m

e n ts fo

r a n d a

g a in

st it are largely relevant to the latter.

W hat argum

ents m ight be offered to support

active voluntary euthanasia? T he strongest one

d e riv

e s fro

m th

e p

rin c ip

le o

f a u to

n o m

y --a

p e r-

s o

n 's

in h

e re

n t rig

h t o

f s e

lf-d e

te rm

in a

tio n

. P ro

- ponents say that respecting autonom

ous persons m

e a n s re

s p e

c tin

g th

e ir a

u to

n o m

o u s c

h o ic

e s ,

in clu

d in

g th

e ch

o ice

to e

n d

th e

ir live s in

th e

ir ow

n w ay. T

heir right is preem m

ent, its only lim it

m a rka

n g th

e p

o in

t w h e re

th e ir ch

o ice

s b rin

g harm

to others. A s one philosopher explains it,

P ro

p o

n e

n ts

b e

lie v e

th a

t th is

rig h

t to d

ie ,

though strong, does not necessarily com pel oth-

e rs

. A lm

o s t n

o o

n e w

h o s

e rio

u s ly

ra g e s th

e a

u -

to n o m

y a rg

u m

e n t th

in ks th

a t h

a vin

g a

rig h t to

& e

fo rce

s a d

u ty o

n o

th e

rs (p h

ysicm n

s, fo r e

x- am

ple) to help in the dying. A

n o th

e r m

a io

r a rg

u m

e n t fo

r a c tiv

e e

u th

a -

nasia appeals to the principle of beneficence, or m

e rc

y " If w

e a

re m

a p

o s itio

n to

re h

e v e

th e

s e

- v e

re s

u ffe

rin g

o f a

n o

th e

r w ith

o u

t e x c e

s s iv

e c

o s t

to o

u rse

lve s, w

e h

a ve

a d

u ty to

d o

so . T

o re

fu se

w o

u ld

b e

cru e

l, in h

u m

a n

e , a

n d

w ro

n g

. T h

e a

rg u

- m

e n t w

o u ld

ru n so

m e th

in g like

th is. If a

co m

- petent, hopelessly 111 patient in unrelieved agony requests help to be put out of …