EuthanaEuthanasiasia Medical and Medical and

Philosophical Philosophical PerspectivesPerspectives

Nov 2006Nov 2006

Lecture 8

Component 1:Component 1: Agent and subject? Agent and subject?

Agent of death ≠ subject of death Agent of death ≠ subject of death euthanasiaeuthanasia

Agent of death = subject of death Agent of death = subject of death suicidesuicide

Component 2:Component 2: Intention of the Intention of the agent?agent?

To bring about the quick and painless death To bring about the quick and painless death of the subject of the subject euthanasia euthanasia

To relieve the subject’s pain merely (though To relieve the subject’s pain merely (though death is foreseen) ≠ euthanasia (e.g., death is foreseen) ≠ euthanasia (e.g., administration of morphine, tranquilizer)administration of morphine, tranquilizer)

Component 3:Component 3: Motive of the agent? Motive of the agent?

Benevolent – concern for the subject’s best Benevolent – concern for the subject’s best interest interest euthanasiaeuthanasia

Malevolent – concern for the agent’s own Malevolent – concern for the agent’s own interests interests murdermurder

Component 4:Component 4: Causal proximity? Causal proximity?

The agent’s act causes the subject’s death The agent’s act causes the subject’s death euthanasiaeuthanasia

The agent provides environmental factors, The agent provides environmental factors, but the subject’s death is caused by his or but the subject’s death is caused by his or her own action her own action assisted suicideassisted suicide

The agent’s act allows an imminent death The agent’s act allows an imminent death arrive unhindered arrive unhindered let die (e.g., let die (e.g., forgoing forgoing futilefutile life-sustaining treatment life-sustaining treatment))

Doctor Assisted SuicideDoctor Assisted Suicide

Oregon, USAOregon, USA Northern Territory, Northern Territory,

Australia, July 1, 1996 Australia, July 1, 1996 – March 24, 1997– March 24, 1997

Dr. Philip Nitschke Dr. Philip Nitschke

Component 5:Component 5: Outcome? Outcome?

The subject indeed diesThe subject indeed dies Otherwise, this is only an euthanasia Otherwise, this is only an euthanasia

attemptattempt

NB: final phase of a terminal illnessNB: final phase of a terminal illness

It is not a component in this notional It is not a component in this notional analysis of euthanasiaanalysis of euthanasia

It can be used as a criterion of admitting It can be used as a criterion of admitting patients to this procedurepatients to this procedure

Active euthanasiaActive euthanasia

Terminating life via actionTerminating life via action Causing death by commissionCausing death by commission Dying and death occur as a causal Dying and death occur as a causal

consequence of an actionconsequence of an action E.g., lethal injectionE.g., lethal injection

Passive euthanasiaPassive euthanasia

Terminating life via inaction Terminating life via inaction Causing death by omissionCausing death by omission Dying and death occur as a causal Dying and death occur as a causal

consequence of an inactionconsequence of an inaction E.g., starving a Downs Syndrome baby who E.g., starving a Downs Syndrome baby who

is dependent on you for feedingis dependent on you for feeding E.g, Taiwan: wife of a medical doctorE.g, Taiwan: wife of a medical doctor (NB: the motives are not necessarily benevolent)(NB: the motives are not necessarily benevolent)

Response or reflex?In this image taken from four hours of videotape, the Schindlers argued that Terri was able to respond to her mother.

How about the How about the case of Terri case of Terri Schiavo Schiavo (2005)?(2005)?

Voluntary euthanasiaVoluntary euthanasia Non-voluntary euthanasiaNon-voluntary euthanasia Involuntary euthanasiaInvoluntary euthanasia

Forgoing futile life-sustaining Forgoing futile life-sustaining treatments ≠ Passive Euthanasiatreatments ≠ Passive Euthanasia

Cardiopulmonary Cardiopulmonary resuscitationresuscitation

SurgerySurgery DialysisDialysis Ventilator Ventilator

AntibioticsAntibiotics I.C.U. admissionI.C.U. admission Artificial nutrition Artificial nutrition

and hydration (?)and hydration (?)

Not to obstruct artificially a natural and Not to obstruct artificially a natural and imminent death imminent death

(withholding (withholding andand withdrawing treatments) withdrawing treatments)

≠ ≠ killing, terminating lifekilling, terminating life

p.v.s. and euthanasiap.v.s. and euthanasia

Is artificial hydration and nutrition a medical Is artificial hydration and nutrition a medical treatment? treatment?

Or is it a humane support to a temporarily Or is it a humane support to a temporarily disabled person?disabled person?

Arguments in Favour ofArguments in Favour of

Voluntary EuthanasiaVoluntary Euthanasia

1. Argument of Mercy1. Argument of Mercy

Duty to relieve painDuty to relieve pain

vs. vs.

Duty to preserve lifeDuty to preserve life

Intolerable painIntolerable pain

Meaningless pain

〝〝 Dr. DeathDr. Death 〞〞 (Dr. Kevorkian)(Dr. Kevorkian)and his “Mercitron”and his “Mercitron”

仁：不忍人之心

Philosophical question: How to cope with pain & suffering ？

臨終關懷善終服務寧養服務

愚仁？

2 Argument of Death with Dignity

Back to the state of infancy (confined to bed; incontinence, feeding, weak consciousness) Dependence

寧為玉碎，不作瓦存寧為玉碎，不作瓦存Death as termination of a degrading lifeDeath as termination of a degrading life

““Undignified health conditions”:Undignified health conditions”:incurable, but not terminalincurable, but not terminal

Alzheimer's diseaseAlzheimer's disease Parkinson's diseaseParkinson's disease ALS, Amyotrophic lateral sclerosis (Lou ALS, Amyotrophic lateral sclerosis (Lou

Gehrig’s disease)Gehrig’s disease) Multiple sclerosisMultiple sclerosis QuadriplegicQuadriplegic PVS, persistent vegetative statePVS, persistent vegetative state

另外，得病后，他再也无法站另外，得病后，他再也无法站上心爱的讲台，这使要强的他上心爱的讲台，这使要强的他心理上无从慰藉。生病以后，心理上无从慰藉。生病以后，常常有大量的学生来到病榻前常常有大量的学生来到病榻前探望老师，甚至有学生多次从探望老师，甚至有学生多次从绵阳赶到成都探病。但因为病绵阳赶到成都探病。但因为病痛，他已经越来越没有一个老痛，他已经越来越没有一个老师的尊严了。他不愿再让学生师的尊严了。他不愿再让学生看到自己老师面对死亡时的狼看到自己老师面对死亡时的狼狈相。他希望轻松体面的生活狈相。他希望轻松体面的生活在世界上，如果生不如死，他在世界上，如果生不如死，他宁愿有尊严地死去。宁愿有尊严地死去。

33岁的语文老师渴望“安乐死”

Philosophical Question: Philosophical Question: Are debilitating health and Are debilitating health and dependence humiliating & dependence humiliating &

undignified?undignified?

Aussie Senate Cmt, 1997Aussie Senate Cmt, 1997

““With very few exceptions, pro-euthanasia With very few exceptions, pro-euthanasia submissions which dealt with the term submissions which dealt with the term ‘dignity’ described particular physical ‘dignity’ described particular physical circumstances and described living or dying circumstances and described living or dying in such circumstances as necessarily in such circumstances as necessarily involving a loss of dignity. These involving a loss of dignity. These circumstances regularly included loss of circumstances regularly included loss of continence and mobility…..continence and mobility…..

““A disturbing equation is thus drawn A disturbing equation is thus drawn between having ‘dignity’ and being ‘without between having ‘dignity’ and being ‘without disability’…. Any notion that those who disability’…. Any notion that those who choose the path of natural death or those choose the path of natural death or those who choose to live with disabilities are in who choose to live with disabilities are in some way taking the less dignified path some way taking the less dignified path should be abhorrent to any caring society.should be abhorrent to any caring society.

Unfortunately, the attitude from certain Unfortunately, the attitude from certain quarters that dying with dignity demands quarters that dying with dignity demands that life ends before such circumstances that life ends before such circumstances begin carries a message which only serves begin carries a message which only serves to devalue those who live in such to devalue those who live in such circumstances” (p.126) circumstances” (p.126)

Morrie SchwartzMorrie Schwartz ““it’s the ultimate sign of dependency. it’s the ultimate sign of dependency.

Someone wiping your bottom.” Someone wiping your bottom.” Felt a little ashamed because of our cultureFelt a little ashamed because of our culture Ignore the cultureIgnore the culture Began to enjoy; it’s like going back to being a Began to enjoy; it’s like going back to being a

child again – bathing, lifting, wiping youchild again – bathing, lifting, wiping you We all yearn in some way to return to those We all yearn in some way to return to those

days when we were completely taken care of days when we were completely taken care of – unconditional love, unconditional attention. – unconditional love, unconditional attention. Most of us didn’t get enough.Most of us didn’t get enough.

Should human mortality be accepted or be deemed unacceptable and to be overcome?

31.10.2004

Dr. Helga Kuhse, Monash Univ.Dr. Helga Kuhse, Monash Univ. ““A dignified death is one which accords with A dignified death is one which accords with

the patient’s values and beliefs, a death that the patient’s values and beliefs, a death that does not contradict the patient’s own view of does not contradict the patient’s own view of what it means to lead a good human life and what it means to lead a good human life and die a dignified death. A mode of dying that die a dignified death. A mode of dying that is prescribed by the imposition of the moral is prescribed by the imposition of the moral or religious beliefs of others is not a dignified or religious beliefs of others is not a dignified death – even if it is relatively pain-free.” death – even if it is relatively pain-free.” ((Quoted from Quoted from Euthanasia Laws BillEuthanasia Laws Bill, 1997, p.61), 1997, p.61)

An even more extreme view !An even more extreme view !

33. . Argument of AutonomyArgument of Autonomy

Right to DieRight to Die

timing timing circumstancescircumstances

Echoes with other bioethical viewsEchoes with other bioethical views

““To be human is to be in control”To be human is to be in control” Death control as well as birth controlDeath control as well as birth control Human-controlled death is better than a Human-controlled death is better than a

natural death natural death （（盡其天年 盡其天年 接受命運擺接受命運擺佈佈）） Voluntary euthanasia is a human right!Voluntary euthanasia is a human right!

Right to euthanasiaRight to euthanasia

Legal right – legalization of euthanasiaLegal right – legalization of euthanasia Moral right – euthanasia is sometimes Moral right – euthanasia is sometimes

morally permissible, though still might be morally permissible, though still might be illegalillegal

Voluntariness – genuine? Or under Voluntariness – genuine? Or under pressure?pressure?

Example:Example:

A right to do X≠It is right to do XA right to do X≠It is right to do X

Freedom to do XFreedom to do X ≠ ≠Doing X is morally Doing X is morally

rightright

Examples:Examples:

Hawking on Hawking on 斌仔斌仔 ““I think he should have the right to end his I think he should have the right to end his

life, if he wants. But I think it would be a life, if he wants. But I think it would be a great mistake. However bad life may seem, great mistake. However bad life may seem, there is always something you can do, and there is always something you can do, and succeed at. While there’s life, there is succeed at. While there’s life, there is hope.”hope.”

Stoke-on-Trent Repertory Theatreproudly present;

Whose Life is it Anyway? - by Brian Clarke.

•Play, 1970 (?)•BBC, 1972•Broadway, 1978•MGM, 1981

GETncm/justsaycust-recrate-itemcommunittg/stores/dtg/stores/d-favorite-listruejust-say-no

1/1/05 --16/1/05

Freedom Freedom andand AccountabilityAccountability

A House is a

Philosophical Question: Philosophical Question: My life – ownership & ruling?My life – ownership & ruling?

sovereigntysovereignty 主權主權 God,God, Heaven, Heaven,

Parents, Parents, SocietySociety

stewardshipstewardship 治權治權 Human BeingsHuman Beings

Euthanasia in the NetherlandsEuthanasia in the Netherlands

PROSTITUTIONPROSTITUTION

                                 

DRUGSDRUGS

GAY MARRIAGEGAY MARRIAGE

                                                 

           

““Situation of Necessity”Situation of Necessity”

A doctor facing a conflict of two dutiesA doctor facing a conflict of two duties The duty to preserve lifeThe duty to preserve life The duty to relieve sufferingThe duty to relieve suffering The prevalence of the second dutyThe prevalence of the second duty

The Report of the Medical Association’s Executive The Report of the Medical Association’s Executive Board (1984): euthanasia performed by a doctor will Board (1984): euthanasia performed by a doctor will

be acceptable when the doctor has met five be acceptable when the doctor has met five “requirements of careful practice”“requirements of careful practice”

1. the request for euthanasia must be voluntary;1. the request for euthanasia must be voluntary;2. the request must be well-considered;2. the request must be well-considered;3. the patient’s desire to die must be a lasting one;3. the patient’s desire to die must be a lasting one;4. the patient must experience his suffering as 4. the patient must experience his suffering as

unacceptable for him;unacceptable for him;5. the doctor concerned must consult a colleague. 5. the doctor concerned must consult a colleague.

Unbearable pain:Unbearable pain: suffering is suffering is intrinsicallyintrinsically subjective and does not allow subjective and does not allow for objective standard of bearablenessfor objective standard of bearableness

No realistic prospect of No realistic prospect of improvement:improvement: no realistic chance of no realistic chance of success within a reasonable period success within a reasonable period

The Purpose of Euthanasia:The Purpose of Euthanasia:

To avoid a To avoid a bad deathbad death??

To terminate a To terminate a bad lifebad life??

NEW DEVELOPMENT: NEW DEVELOPMENT: 1. PSYCHIC PAIN1. PSYCHIC PAIN

The psychiatrist Chabot had assisted a 50-year-old woman in committing suicide, 1991. The woman suffered from severe depression, and after the death of her two sons and the break-up of her marriage she did not want to live any longer.

“Intolerable psychological suffering is no different from intolerable physical suffering.” (Dr. Chabot)

Dr. Chabot invoked Dr. Chabot invoked force majeureforce majeure. . This was not granted, because This was not granted, because none of the colleagues that Dr. none of the colleagues that Dr. Chabot had consulted had actually Chabot had consulted had actually examined the woman. examined the woman.

But the Court also held that But the Court also held that invoking invoking force majeureforce majeure could be could be allowed in cases where the allowed in cases where the suffering is purely psychological.suffering is purely psychological.

definition of euthanasia definition of euthanasia

“ “the killing of those who are the killing of those who are incurablyincurably ill and ill and in great pain or in great pain or distressdistress in order to spare in order to spare them further suffering.” (Peter Singer, 1979, them further suffering.” (Peter Singer, 1979, p.127) p.127)

2. TIRED OF LIFE2. TIRED OF LIFE

In 1998 Dr. Sutorius assisted 86-year-In 1998 Dr. Sutorius assisted 86-year-old former senator Edward Brongersma old former senator Edward Brongersma in terminating his life. in terminating his life.

Brongersma was not terminally ill, was Brongersma was not terminally ill, was not in pain and did not suffer from any not in pain and did not suffer from any psychological disorders. He simply psychological disorders. He simply believed his life was not worth living any believed his life was not worth living any more, because he felt lonely and could more, because he felt lonely and could no longer put his qualities to good use. no longer put his qualities to good use.

FIRST COURT VERDICTFIRST COURT VERDICT

The court went along with expert opinion The court went along with expert opinion and ruled that Brongersma was indeed and ruled that Brongersma was indeed suffering unbearably and that there was no suffering unbearably and that there was no hope for any improvement in his situation hope for any improvement in his situation and acquitted Dr Sutorius. and acquitted Dr Sutorius.

THE APPEALTHE APPEAL The Justice Ministry appealed because it The Justice Ministry appealed because it

is extremely wary of stretching the rules is extremely wary of stretching the rules laid down in the euthanasia law any laid down in the euthanasia law any further. further.

In appeal the court of justice said that in In appeal the court of justice said that in this case there is no unbearable and this case there is no unbearable and unrelenting suffering. It convicted Dr unrelenting suffering. It convicted Dr Sutorius of assisting with suicide but did Sutorius of assisting with suicide but did not pass sentence, because he had acted not pass sentence, because he had acted out of compassion (Dec 6, 2001). out of compassion (Dec 6, 2001).

3. NURSES3. NURSES In 1995 a nurse was handed a In 1995 a nurse was handed a

suspended prison sentence of two suspended prison sentence of two months for terminating the life of a months for terminating the life of a friend who suffered from AIDS. She had friend who suffered from AIDS. She had consulted a doctor who had supplied consulted a doctor who had supplied her with the means. her with the means.

The court ruled that only doctors could The court ruled that only doctors could perform euthanasia. perform euthanasia.

4. BABIES4. BABIES In 1995 The Court acquitted, Dr. Prins, a In 1995 The Court acquitted, Dr. Prins, a

gynaecologist who had administered a gynaecologist who had administered a lethal injection to a lethal injection to a three-day oldthree-day old baby baby suffering from spina bifida and suffering from spina bifida and hydrocephalus. The baby was in extreme hydrocephalus. The baby was in extreme pain and was expected to live no longer pain and was expected to live no longer than six months. The parents had than six months. The parents had requested euthanasia. The gynaecologist requested euthanasia. The gynaecologist successfully invoked successfully invoked force majeureforce majeure. .

In 1994 a euthanasia was performed on a In 1994 a euthanasia was performed on a 24-day old24-day old baby girl, who was suffering from baby girl, who was suffering from an incurable congenital disorderan incurable congenital disorder

The court accepted Dr. Kadijk’s defence of The court accepted Dr. Kadijk’s defence of justification due to necessity (1995, 1996)justification due to necessity (1995, 1996)

Sources of Information:

1. Radio Netherlands

http://www.rnw.nl/society/html/euthanasiaindex.html

2. John Griffiths, Alex Bood, and Heleen Weyers, Euthanasia & Law in the Netherlands (1998)

Kinds of suffering eliminated by Kinds of suffering eliminated by euthanasia in the Netherlandseuthanasia in the Netherlands

PhysicalPhysical Mental, emotional (distress, anguish, agony, Mental, emotional (distress, anguish, agony,

grief)grief) Existential or spiritualExistential or spiritual

Issue: Can they and must they be eliminated Issue: Can they and must they be eliminated by technology? Or they could and should by technology? Or they could and should be addressed otherwise?be addressed otherwise?

Kinds of euthanasia practicedKinds of euthanasia practiced

Voluntary and activeVoluntary and active Non-voluntary and activeNon-voluntary and active

Tutorial Tutorial DiscussionDiscussion Topics: Topics: Peter Singer, Peter Singer, Practical EthicsPractical Ethics, “Taking Life: , “Taking Life:

Euthanasia,” pp.127-Euthanasia,” pp.127-139.139. According to Singer, taking the life of According to Singer, taking the life of

defective infants (i.e., non-voluntary defective infants (i.e., non-voluntary euthanasia) involves two considerations: euthanasia) involves two considerations: individual consideration (is the infant’s life individual consideration (is the infant’s life going to be worth-living?) and social going to be worth-living?) and social consideration (will the infant’s life bring consideration (will the infant’s life bring about a greater, total amount of happiness?)about a greater, total amount of happiness?)

1.1. Please explain the first consideration with Please explain the first consideration with reference to the case of Spina Bifida, reference to the case of Spina Bifida, 脊柱脊柱裂 裂 (pp.132-133). (pp.132-133).

2.2. Please explain the second consideration Please explain the second consideration with reference to the cases of with reference to the cases of Haemophilia, Haemophilia, 血友病血友病 , and , and Down’s Down’s Syndrome, Syndrome, 唐氏綜合症 唐氏綜合症 (pp.133-138).(pp.133-138).

3. 3. According to Singer’s discussion of other According to Singer’s discussion of other cases of nonvoluntary euthanasia on cases of nonvoluntary euthanasia on pp.138-139, would he agree with stopping pp.138-139, would he agree with stopping artificial nutrition and hydration for Terry artificial nutrition and hydration for Terry Schiavo (a patient in permanent vegetative Schiavo (a patient in permanent vegetative state)? Explain.state)? Explain.

Peter SingerPeter Singer Ira W. DeCamp Professor Ira W. DeCamp Professor

of Bioethics, University of Bioethics, University Center for Human Values, Center for Human Values, Princeton University, 1999-Princeton University, 1999-2004, part-time, 2005- 2004, part-time, 2005-

Laureate Professor, Laureate Professor, University of Melbourne, University of Melbourne, Centre for Applied Centre for Applied Philosophy and Public Philosophy and Public Ethics, part-time 2005- Ethics, part-time 2005-

http://www.princeton.edu/http://www.princeton.edu/~psinger/~psinger/