EUTHANASIA

Edvard Munch, Death in the Sickroom,1895

“Doctors Must Not Kill”

Edmund D. Pellegrino

SUFFERING AND EUTHANASIA

• Pellegrino is a physician and writes about euthanasia from that perspective.

• His position is that, while doctors have a duty to alleviate suffering, they cannot knowingly and willingly involve themselves in the death of a patient.

• And this is the case even if the patient requests it. Thus his view is opposed to voluntary active euthanasia as well as to nonvoluntary and involuntary euthanasia.

PELLEGRINO’S POINTS• Although Pellegrino says that “No one can

reasonably oppose a ‘good’ death,” he is opposed to euthanasia “even out of compassion” for the following reasons.

• 1. Moral arguments for euthanasia are not convincing.

• 2. Euthanasia distorts the healing relationship between doctor and patient.

• 3. Euthanasia is likely to be abused by society, and so can have terrible social consequences.

ARGUMENTS FOR EUTHANASIA I• Those who argue for euthanasia typically say the

following basic things:• 1. Euthanasia eliminates suffering, suffering is evil, and

so euthanasia is good because it eliminates suffering.• 2. People who are suffering from a terminal illness have

the right to choose not to suffer. And if euthanasia is the only means of ending suffering, then those suffering have the right to end their suffering by ending their lives. This is the principle of autonomy.

• 3. Terminally ill patients cannot end their own lives, but depend on doctors who know best how to do it. Here a doctor acts as an agent on behalf of the patient.

ARGUMENTS FOR EUTHANASIA II

• 4. Because part of a doctor’s moral duty is to end suffering, she has a moral duty to assist a patient in obtaining a good death when that is the patient’s desire.

• 5. There is no moral difference between a doctor’s killing a patient and letting her die. [Rachels.]

• 6. Abuses of euthanasia can be controlled by legislation.

• 7. “No physician who is morally opposed need participate.”

EUTHANASIA AND RELIGION I

• Two arguments against euthanasia from the Judeo-Christian tradition are:

• 1. Humans are given the gift of life and have no right to interfere with this gift. [Plato.]

• 2. Even human suffering can have meaning, that is, it can be meaningful in a positive way.

• Although Pellegrino thinks that these arguments are “not lightly dismissed,” he says that he will not try to make his argument against euthanasia by appeal to these things. And this is because “Even without recourse to religious beliefs, active euthanasia is morally untenable.”

EUTHANASIA AND RELIGION II

• Pellegrino does say, however, that these are beliefs which are deeply rooted in our culture, and because they are so deeply rooted, he thinks that the burden of proof is on the person who argues against these beliefs in arguing for euthanasia.

• The idea here then is that someone who wants to argue against tradition and common opinion must give good reasons for doing so, and he thinks that the arguments offered in favor of euthanasia are not proof that it is morally acceptable.

KILLING AND LETTING DIE I• Pellegrino will first look at the idea made by some advocates of

euthanasia that there is no moral difference between killing a patient and letting him die “by deliberate withdrawal or withholding of life support or lifesaving treatment.”

• The moral parity of killing and letting die can be understood to have two aspects whether it concerns a moral good or a moral evil.

• That you are as guilty of a wrongdoing if you let someone die whose death you could have prevented as you are in killing her is to see killing and letting die as equally morally evil.

• On the other hand, if letting someone die - passive euthanasia - is a moral good because it ends suffering, then why is not killing someone to end suffering - active euthanasia - also not a moral good? Aren’t these equally morally good?

KILLING AND LETTING DIE II

• For Pellegrino, the difference is that in active euthanasia the doctor is the direct cause of the patient’s death, whereas in letting the patient die or passive euthanasia the illness is the cause of death.

• Therefore he does not see them as morally equivalent because in the first case the doctor does something and in the second instance he does nothing.

KILLING AND LETTING DIE III

• James Rachels’ response is that it is not true that in passive euthanasia the doctor does nothing.

• After all, he lets the patient die, and letting someone die can be subject to moral evaluation - good or bad - as we have seen.

• Rachels says that if passive euthanasia is seen as medically acceptable, then that is because it is seen that death is an equal or lesser evil than suffering.

• And if passive euthanasia is acceptable to eliminate the equal or greater evil of suffering, then, for Rachels, so is active euthanasia.

EUTHANASIA AND AUTONOMY I

• Pellegrino next looks at the argument for euthanasia based on the patient’s right of autonomy.

• The right of autonomy is the right to self-determination - to make free choices for yourself.

• This could include a terminally ill patient’s right to choose to die to end her pain and suffering. The idea is whose life is it anyway?

EUTHANASIA AND AUTONOMY II

• Pellegrino’s problem with the right to autonomy is that, in exercising her right to die, a person is using her freedom to give up her freedom.

• Thus, in the name of autonomy the patient decides to end the life which makes autonomy possible.

• When you give up your life you give up everything, including your freedom and “control over a whole set of options, all of which cannot be foreseen and many of which would be of importance if life - the basis of freedom - had not been forgone.”

EUTHANASIA AND AUTONOMY III

• However, a proponent of euthanasia might argue that a dying patient’s using freedom to eliminate freedom is not a contradiction but is simply a use to which freedom is practically put, given his illness and suffering.

• And it might be further argued that, if the medical condition of the patient is such as to restrict or eliminate all future meaningful options, then the most meaningful thing for freedom to do is to eliminate the life which supports the suffering.

EUTHANASIA AND AUTONOMY IV• Pellegrino also says in regard to autonomy that, if the

patient chooses death because of unbearable suffering, then the choice of death is “really not free.”

• But again, a euthanasia advocate might argue that, even if this is the case, and the patient is powerless to act otherwise, euthanasia can yet be seen as the only option to eliminate the evil of suffering.

• And here autonomy could yet be relevant in the patient’s having made the free choice to opt for euthanasia if such a medical condition as he now experiences were ever to arise. The patient would have simply exercised his freedom earlier in his life by planning for such an event through a will.

THE BURDEN OF TERMINAL ILLNESS

• Pellegrino says that terminally ill patients often see themselves as social, economic, and emotional burdens to others.

• And in their debilitated condition they may be susceptible to subtle suggestion - such a doctor’s agreeing that they are a burden. They could then decide to choose euthanasia.

• For Pellegrino, “euthanasia is too often an act of desperation” - an act that could be avoided if pain is properly managed.

• But what about the cases where pain cannot be properly managed? And what about the medical conditions which are so terrible that modern medicine can do nothing for them?

KINDNESS AND COMPASSION I

• Advocates of euthanasia will cite kindness and compassion as reasons for ending through death the terrible suffering of a terminally ill patient.

• Pellegrino recognizes that compassion is part of medicine, since every doctor desires to make his patients well, and he recognizes that even those who see meaning in suffering would prefer that someone not suffer.

• Do not compassion and mercy then override all other considerations?

KINDNESS AND COMPASSION II

• The answer to this, for Pellegrino, is that compassion can concern removing the dying patient’s pain without resorting to euthanasia.

• By removing a patient’s pain, he can experience a “good death” - the one which nature intended.

• Pellegrino: “The aim of medicine should be to facilitate a death that is as pain-free as possible but that is also a human experience.”

DYING, EXPERIENCE, AND UNDERSTANDING

• Euthanasia of humans is morally unacceptable for Pellegrino because they have the capacity to understand the experience of dying, and possibly benefit from it, whereas such understanding is not possible for other ‘lower’ life forms such as “our pets.”

• The experience of dying is important for Pellegrino since “humans can grow morally even with negative experiences.”

• Notice that dying can be treated as an experience for a person who is conscious while his life is ending, whereas death, at least from the perspective of life on earth, is the end of all experience.

• [See the first two full paragraphs on page 176 and compare with the questions for Pellegrino on the handout.]

THE MOTIVATION FOR EUTHANASIA

• Pellegrino says that “The motivation for euthanasia arises principally from two worries: fear of intolerable pain, suffering, and anguish, and fear of becoming a victim of overzealous physicians and dehumanizing medical technologies.”

• Although Pellegrino recognizes that both of these are “legitimate worries,” he thinks that each can be handled “without resort to euthanasia” through “improved measures for relief of pain and anxiety” which physicians have a moral obligation to use, and through “hospice programs and palliative care.”

MAKING DYING POSITIVE

• With the help of such programs, dying, according to Pellegrino, can be “a communal experience, in which the dying person contributes something positive to those around her as well as to her own growth as a person.”

• And Pellegrino thinks that “the physician’s obligation to act beneficently and to show respect for the patient’s dignity is better served by these measures than by killing the patient.”

MAJORITY OPINION

• Pellegrino points out, correctly, that that the majority of people believe something does not make it morally correct or incorrect. Thus comment consent does not guarantee the truth of whatever it is about which the majority agree, and philosophical argument with relevant evidence must be established to determine the truth of something, not popular opinion.

• If the majority is in favor of euthanasia that does not in itself show that euthanasia is morally correct, and if most people are against, that majority opinion also does not show that euthanasia is immoral.

DISTORTING THE HEALING RELATIONSHIP I

• According to Pellegrino, euthanasia distorts the healing relationship between doctor and patient.

• A doctor’s aim is to heal her patient if possible, and if that is not possible, then the physician has an obligation to treat the patient’s pain to the best of her ability.

• [Notice that he says this in spite of his respect for the moral value of suffering. Is this a problem for his view?]

• Pellegrino notes that medicine is grounded in trust, and he thinks that euthanasia could destroy that trust.

DISTORTING THE HEALING RELATIONSHIP II

• Euthanasia could destroy the patient’s trust of his doctor since, if euthanasia were legal, then some doctors might opt for killing their patients rather than healing them.

• The doctor who thinks his patient is better off dead might try to convince his patient to end his life rather than waiting to die naturally.

• This is the slippery slope idea that if we legalize euthanasia then abuses of the system would inevitably occur, human nature being what it is.

A SLIPPERY SLOPE I• As Mary Warnock puts it: “The ‘slippery slope’ is the name

of an argument based on a certain view of human nature, not on logic, and commonly used in nonphilosophical discussions of moral issues.”

• Warnock: “The reasoning is that, though a practice may be unobjectionable in one type of case, if it is once permitted, its use will inevitably be extended to other more morally dubious cases.”

• Warnock: “The inevitability here supposed is not logical inevitability, but is thought to result from people’s always wanting more than they have.”

• Warnock: “In fact, legislation or other forms of regulation can usually control an undesirable slide down the slippery slope.”

A SLIPPERY SLOPE II• According to the slippery slope argument then,

although a certain kind of practice may be acceptable in one kind of case, once it is permitted, it will be extended to cases where it ought not to be used.

• The idea is that we slide down the slope from a good thing to a bad thing.

• In this instance, if euthanasia were okay for one kind of terminally suffering patient, it would be used in cases where it should not - where it is not really the wish of the patient to be put to death.

A SLIPPERY SLOPE III

• A slippery slope argument such as this depends on seeing human beings as basically morally irresponsible, unable to make reasonable judgements, susceptible to external influence, or all of these.

• The common rebuttal to such slippery slope arguments is that potential bad cases can be prevented through proper legislation.

• Advocates of euthanasia, such as James Rachels, recognize the possibility of system abuses, but are willing to rely on legislation and the good judgement of the medical community to correct them.

A SLIPPERY SLOPE IV

• The idea then is that the remedy for abuses is either to enforce legislation so that they don’t occur, and if the violations become too excessive you simply repeal the law which legalized euthanasia.

• But Pellegrino might respond that this is not a risk worth taking. In fact he says that “laws will not prevent abuses,” and thinks that abuse “is inevitable.”

• On the other hand, James Rachels is a philosopher who thinks that the benefits of euthanasia will outweigh any abuses that may occur.

A SLIPPERY SLOPE V

• Whatever the case about likely abuses of euthanasia though, Pellegrino’s view is that the doctor has an obligation to alleviate or eliminate suffering so that the patient could experience a good death, and she must reject euthanasia since that eliminates the prospect of a good death and distorts the healing relationship between doctor and patient.

“VOLUNTARY ACTIVE EUTHANASIA”

Dan W. Brock

V.A.E. AND P.A.S. I

• Brock thinks that both euthanasia and physician assisted suicide are morally permissible.

• Remember that voluntary active euthanasia (v.a.e.) is when the doctor intentionally kills a terminally ill patient with the patient’s consent.

• In physician assisted suicide (p.a.s.) the patient kills herself with the assistance of the doctor, the doctor does not act directly to kill the patient.

V.A.E. AND P.A.S. II

• In physician assisted suicide, the patient is the one who directly ends her own life.

• An example of physician assisted suicide is when a patient ends her life with a drug that the doctor prescribes.

• In voluntary active euthanasia, the doctor directly kills the patient at the request of the patient.

• In voluntary active euthanasia the doctor or a medical assistant acting on the doctor’s orders administers the drug to the patient.

V.A.E. AND P.A.S. III

• In both euthanasia and assisted suicide “the choice [of death] rests fully with the patient. In each case “the patient acts last in the sense of retaining the right to change his or her mind.”

• And in each case the doctor is directly involved, and “plays an active and necessary causal role.”

• In fact, for Brock, “the only difference that need exist between the two [v.a.e. and p.a.s.] is the person who actually administers the dose - the physician or the patient.”

• Brock wants to know then how there could be “a substantial moral difference between the two [v.a.e. and p.a.s.] based only on this small difference in the part played by the physician in the causal process resulting in death?”

V.A.E. AND P.A.S. IV• Thus Brock wonders why some people think that there is

a major moral difference here between euthanasia and assisted suicide since the doctor is necessarily and actively involved in both cases.

• Some might respond that the moral difference is clear since in euthanasia the doctor kills the patient, while in p.a.s the patient kills the patient, with, of course, the doctor’s assistance.

• But Brock says that “this is misleading at best.”• It’s misleading because in p.a.s the doctor and patient

together kill the patient. And they do it together since the patient cannot kill himself without the doctor’s help.

V.A.E. AND P.A.S. V

• Brock points out that, if a doctor gave a patient a lethal dose of medication with full knowledge that the patient will use it to kill someone else, we would hold the doctor responsible for a wrongful death.

• So if the doctor gives his patient a lethal drug with the full knowledge that he will use it to kill himself then he is also responsible for the death of the patient.

• And Brock says that if it is really the case that there is no significant difference between euthanasia and p.a.s, then why should people be in favor of one and not the other?

• Accordingly, a law which permitted p.a.s. on moral grounds ought also to permit euthanasia on moral grounds.

THE CENTRAL ARGUMENT FOR EUTHANASIA

• Brock will focus on voluntary active euthanasia only, which I will call ‘euthanasia’ for short.

• The argument for euthanasia comes typically from two fundamental moral points regarding persons:

• 1. The right to self-determination [the right of autonomy].

• 2. The right to well-being.• A person’s right to self-determination is his or her right to

make free choices about his or her life to the extent that such choices do not interfere with someone else’s right to self-determination.

• And a person’s right to well-being includes the right not to suffer, physically, psychologically, or both.

SELF-DETERMINATION I

• Self-determination in regard to euthanasia means that a terminally ill patient whose suffering only death will end has the right to decide about her own life.

• Thus a person suffering from a terminal illness should be free to make up her own mind about her future in relation to that illness.

• We take self-determination to be a good thing, and we take suffering to be a bad thing.

SELF-DETERMINATION II

• Brock says that “By self-determination as it bears on euthanasia, I mean people’s interest in making important decisions about their lives for themselves according to their values or conceptions of a good life, and in being left free to act on those decisions.”

• For Brock, self-determination is both valuable and “a central aspect of human dignity.”

• Basing euthanasia on the right of self-determination means that people must have the ability to decide for themselves.

SELF-DETERMINATION III

• Basing euthanasia on the right of self-determination also “presupposes some minimum of decision-making capacities or competence . . . and cannot justifiably be administered, for example, in cases of serious dementia or treatable clinical depression.”

• Those in favor of euthanasia would say the right to self-determination extends to a person’s right to decide about her own death.

• For them, we ought to have the right to discontinue our lives when faced with terminal suffering.

SELF-DETERMINATION IV

• People have a natural fear of suffering and a fear of losing dignity due to illness, and euthanasia would give them an option then to avoid both.

• However, Brock says that everyone has to decide for himself, and that people and life are complicated enough that “there is no single objectively correct answer for everyone” about how much suffering you can take, and about when loss of dignity will occur.

• Accordingly, where euthanasia may be proper for some it may not be for others, and this is why the emphasis is on euthanasia being voluntary.

• Because people are so different, and the right of self-determination is so important, it is especially important that terminally ill people are able to “control the manner, circumstances, and timing of their dying and death.”

WELL-BEING• We think that life is good and death is evil, but, more

particularly, we think that a healthy life is good and that suffering is an evil. And we think that everyone has a right to well-being - that no one should suffer who does not have to.

• Proponents of euthanasia say that, since everyone has a right to well-being, and a right to self-determination, when someone loses her feeling of well-being; when life becomes an unbearable burden; and when a life of suffering is “worse than no further life at all,” then a person has the right to end her suffering through death.

• Again, Brock says that “there is no objective standard [about what constitutes an unbearable life], but only the competent patient’s judgement of whether continued life is no longer a benefit.”

PHYSICIANS AND EUTHANASIA

• Brock says that a person’s right to self-determination cannot be used to compel doctors to practice euthanasia or p.a.s.

• If a doctor objects to either on moral grounds, then she cannot be forced to participate in bringing about the death of the patient.

• That is, the doctor’s right of self-determination also has to be respected.

• Even if euthanasia becomes legal, a doctor who objects to it need not be involved, and his role can be taken by another willing physician.

ARGUMENTS AGAINST EUTHANASIA

• Two main arguments against euthanasia cited by Brock are:

• 1. The deliberate killing of an innocent person is always ethically wrong.

• 2. Perhaps euthanasia is morally acceptable in certain cases, but it ought not to be legally permitted since it will be abused, and so the bad consequences will outweigh the good. [Slippery slope.]

DELIBERATE KILLING OF AN INNOCENT PERSON I

• Opponents of euthanasia say that euthanasia is the deliberate killing of an innocent person, and they object to euthanasia because they think that this deliberate killing is always immoral.

• Brock says that they are right that euthanasia is the deliberate killing of an innocent person.

• The killing is done deliberately at the patient’s request to end her suffering, and the person is not guilty of any crime or wrongdoing in virtue of being terminally ill and suffering.

DELIBERATE KILLING OF AN INNOCENT PERSON II

• The question of the morality of euthanasia then concerns whether or not the deliberate killing of an innocent person is always wrong.

• If it is then euthanasia is immoral.

• If it is not then euthanasia may be permissible, at least in some cases.

KILLING AND ALLOWING TO DIE I

• While some think that voluntary active euthanasia is wrong, they do not think that deliberately allowing a person to die, or passive euthanasia is wrong.

• Thus, allowing someone to die by deliberately withholding life sustaining treatment is thought to be morally acceptable and different from euthanasia, because in allowing to die you are allowing the disease to kill the patient and so the doctor is not killing the patient.

• But Brock says that this view is “confused and mistaken.”

• [See Brock’s example on pp. 188-189.]

KILLING AND ALLOWING TO DIE II

• The idea here is that the same physical actions are performed by the greedy son as by the compassionate physician. If the son’s action is killing why is not the doctor’s?

• Brock understands that there is a difference of intention here, and that both the intention and other considerations make us think that there is a moral difference here.

• For instance, the doctor acts with the patient’s consent, has a good motive - ending suffering - and is performing a social role for which he is legally authorized.

• On the other hand, the son acts without the patient’s consent, with a bad motive - greed - and is not performing a social role for which he is legally authorized.

KILLING AND ALLOWING TO DIE III

• Brock’s point is that these things show that what the doctor did to the patient and what the son did are morally different - one is moral and the other is immoral - but what the example does not show is that “the son killed the patient while the doctor allowed her to die.”

• For Brock, even if we suppose that killing is worse than allowing to die, and that withdrawing life support is allowing to die, while euthanasia is killing, it need not follow that euthanasia is morally wrong.

WHY IS KILLING WRONG I?

• Brock asks: just what is it that makes the deliberate killing of an innocent person wrong?

• He thinks that a good answer is that killing deprives a person of the possibility of having a valuable future. [Don Marquis uses this as an argument against abortion.]

• Every innocent person has a right to the possibility of a valuable future, and as killing deprives a person of this right, killing is wrong. Another way to put this is “people have a moral right not to be killed.”

WHY IS KILLING WRONG II?

• People are a kind of being which can have a sense of the future, can plan for the future, and can see life in the future as something which they value and can anticipate taking pleasure in.

• But making plans for and valuing the future presupposes the continued existence of the life whose plans and valuing they are.

• If that life is ended so is the possibility of realizing those plans, and so ends the possibility of value to be realized in the future.

WHY IS KILLING WRONG III?

• Killing frustrates a person’s plans and ends her dreams of a good future.

• Death is an evil because in death you give up everything.

• Thus an act which deliberately causes a person’s death is seen as an evil because it is the cause of an evil.

• And so people have a moral right not to be killed, not to have the possibility of a good future interfered with.

WRONGFUL KILLING AND EUTHANASIA I

• Whereas deliberate killing of an innocent person may seem to rule out euthanasia as immoral, it does not necessarily. This is because what makes deliberate killing wrong is its depriving a person of a valuable future.

• If the person has no prospect of a good future, then killing her at her request need not be morally wrong.

• A terminally ill patient’s future may be worse than no future at all because of the promise of suffering which will characterize that future.

WRONGFUL KILLING AND EUTHANASIA II

• As much as we think that people have a right to a good future, we also think that everyone has a right to well-being and hence a right not to suffer.

• For Brock, a person’s right not to be killed can be waived by that person. Thus a person can give up her right not to be killed in favor of her right not to suffer.

• Euthanasia then can be seen as morally acceptable since the terminally ill patient chooses to give up her right not to be killed. She deliberately chooses euthanasia since she sees death as the only means of ending her suffering.

RELIGION AND EUTHANASIA• Brock says that many people who feel squeamish about

euthanasia, even when they agree about the evil of suffering, are uncomfortable about euthanasia due to religious reasons.

• However, for Brock, the question of euthanasia concerns the moral correctness or incorrectness of adopting euthanasia as public policy - of making it legal or not - and he thinks that such public policy cannot be grounded on religion in a free society.

• We live in a pluralistic society which consists of many people who accept and others who reject religion, and we have to recognize the strong commitment we have to freedom of belief.

EUTHANASIA AND PUBLIC POLICY• Brock recognizes that it is one thing to talk of the morality of

euthanasia in individual cases where it is requested by a dying patient, and it is another to talk of legalizing euthanasia.

• And here it is pertinent to recognize that, in addition to saying that the deliberate killing of an innocent person is always wrong, the second main argument against euthanasia is that the bad consequences of making it legal would outweigh the good consequences.

• Brock notes that there are two kinds of disagreement about this second argument: “empirical or factual disagreement about what the consequences would be;” and “moral disagreements about the relative importance of different effects [of legalizing euthanasia].”

POTENTIAL GOOD CONSEQUENCES OF

PERMITTING EUTHANASIA

THE RIGHT TO SELF DETERMINATION

• A first good consequence of permitting euthanasia would enable us to respect the right to self-determination of competent patients who ask for it.

• But Brock notes that the opponent of euthanasia could ask here whether we need to respect the right to self-determination in every case, or might some other ethical principles override it?

• If the opponent says that the deliberate killing of another person is always wrong, then this moral law could override the right to self-determination.

• On the other hand, if a competent person can waive his right to be killed in favor of his right not to suffer, then the right not to suffer coupled with the right of self-determination could override morally the principle which says that the deliberate killing of an innocent person is always wrong.

DESIRE FOR EUTHANASIA AS AN OPTION

• When we ask about instituting euthanasia as public policy we would have to ask how many people are likely to want it, and the answer to this will depend to the extent to which the illness is treatable, or the extent to which the suffering is manageable. That is, the question will concern: is euthanasia the only option?

• Brock thinks that the number of people in the U. S. who would want euthanasia is “probably relatively small,” but thinks that it should be available for those who would choose it.

SATISFYING THE MAJORITY• A second good consequence of permitting euthanasia would

be giving the majority what they want. This is because polls show that most Americans want the option of euthanasia even if they would not choose it for themselves when the time came.

• Most people think that a person has the right to choose euthanasia, and making euthanasia legal would reinforce the perception of this moral right.

• Thus it would be reassuring to people to know that euthanasia is an option, should they need it.

• Brock says that this would make euthanasia “a kind of insurance policy” against the threat of interminable suffering.

RELEASE FROM SUFFERING AND AGONY I

• The third good consequence of legalizing euthanasia, according to Brock, is its elimination of horrible suffering when nothing else will take it away, and he suggests that the sad fact is that many patients suffer needlessly for “physicians’ fear of hastening the patient’s death.” This would not be a fear if euthanasia were legal.

• The argument for euthanasia as the only means of eliminating pain or other kind of terrible suffering is the argument from compassion or mercy.

RELEASE FROM SUFFERING AND AGONY II

• Brock says that in talk of pain we must distinguish between pain that is treatable by medication and pain that is not, or pain which only death will remove.

• Brock recognizes that the argument for euthanasia based on the elimination of pain loses much of its force if the pain can be managed without death - even at the cost of making the patient comatose. (Presumably the patient could not die Pellegrino’s “good death” if comatose)

• Thus the argument from compassion can be met if the suffering can be ended without killing the patient. Here then the argument in favor of euthanasia from suffering would depend on there being kinds of suffering which only death can eliminate.

RELEASE FROM SUFFERING AND AGONY III

• Brock mentions psychological pain or suffering in addition to physical pain, and notes that the knowledge of how to treat this is much more limited.

• Thus an argument from compassion for the suffering patient can be made for euthanasia where the psychological suffering is unbearable, and death is the only means of eradicating this suffering.

• And if this kind of suffering is less treatable, then patients suffering psychological pain might be more in need of euthanasia than others.

HUMANITY• A final good consequence of euthanasia is that ending life

quickly and painlessly is more humane than a prolonged death which involves pain and suffering.

• Brock asks, don’t we think that people who die quickly or in their sleep are lucky?

• A psychological factor here is that we care how people remember us, and we don’t want to be remembered as sick and suffering. Thus a debilitating disease can rob us of our dignity.

• For the patient who wants it, euthanasia can be a quick and peaceful end to life which will give some dignity and allow her loved ones to remember her as she was in better times.

POTENTIAL BAD CONSEQUENCES OF

PERMITTING EUTHANASIA

DOCTORS MUST NOT KILL

• A first potential bad consequence of legalizing euthanasia is that permitting doctors to perform euthanasia is incompatible with their professional and moral commitment to heal and care for patients rather than to kill them. (Pellegrino.)

• Permitting doctors to practice euthanasia would remove the trust between doctor and patient and distort the trust which the patient has in the doctor. (Pellegrino.)

• Patients then could no longer be sure that their doctor was not giving them a drug which will kill them rather than reduce pain, and the patient’s trust of his doctor would be eroded.

BROCK’S RESPONSE I

• Brock wonders how legitimate this concern is. How can a patient have a fear about the nature of a certain drug when she has asked for the doctor to perform euthanasia?

• If euthanasia is restricted to cases which are strictly voluntary, then how can a patient who has not requested euthanasia fear anything?

• In fact, Brock thinks that a patient’s trust of her physician could actually be increased.

• Trust would be increased if euthanasia were legal since then a suffering patient would know that she could request it if needed, and could trust that her doctor would honor her request.

BROCK’S RESPONSE II• Brock says recall what the two main arguments for

euthanasia are:• 1. The patient’s right of self-determination.• 2. The patient’s right to well-being.• Brock says that doctors who respected these two basic

rights would not be changing the moral character of medicine. Rather, respect for these two values will support doctors who practice euthanasia when requested by competent patients.

• For Brock, what is morally suspect is practice of medicine without regard for these two basic patient rights.

THE VALUE OF HEALTH CARE

• A second bad consequence of euthanasia is that it could weaken society’s commitment to provide the best care for patients that is possible.

• Because health care is expensive, some might see euthanasia as a cheaper alternative to costly care, and we might use [abuse] euthanasia when other more costly care is available.

BROCK’S RESPONSE• There is little evidence that patient’s right to

refuse treatment - passive euthanasia - has caused patients to receive worse care. And if the possibility of passive euthanasia has not caused the quality of health care to go down, then why should active euthanasia?

• In addition, Brock thinks that very few people would choose euthanasia even if it were available.

• Thus permitting euthanasia should not interfere with the high quality of health care that we have without euthanasia.

PRESSURE TO CHOOSE EUTHANASIA

• A third bad consequence of euthanasia mentioned by Brock is due to David Velleman, who says that “making a new option or choice available to people can sometimes make them worse off.”

• The choice of euthanasia could mean that some people who do not really want to choose euthanasia will be led to choose it by others who see it as the best option for them.

• If euthanasia were not legal, then this option would not exist and the dying patient would not have to consider it. However, if euthanasia is an option, then the choice of it can make the person who does not want it worse off if she thinks that she ought to choose it because others want her to choose it.

• Velleman does not see this as an argument to outlaw euthanasia, but only to restrict it to those who genuinely want it for “unmistakable and overpowering reasons.”

BROCK’S RESPONSE I

• Brock wonders whether it is true that people would be made worse off by having the choice of euthanasia. He says that polls show that most people want the option and so think that they would be made better off and not worse off by having the choice.

• He also maintains that, if giving people the option of euthanasia is a possibly harmful choice for them, then so could be the option of passive euthanasia - refusing life-sustaining treatment.

• However, there is no evidence that this has been a bad option for people.

BROCK’S RESPONSE II• Also, because the conditions for wanting or not

wanting euthanasia are so wide and varied, it is not advisable to restrict it in the way that Velleman suggests.

• It is not advisable since then euthanasia could be denied to people who really want it.

• Brock: “To permit it only in cases where virtually everyone would want it would be to deny it to most who would want it.”

THE PROHIBITION OF HOMICIDE

• The American College Dictionary defines homicide as “the killing of one human being by another,” and Brock says that “This prohibition is so fundamental to civilized society, it is argued, that we should do nothing that erodes it.”

• Because legalizing euthanasia could be seen to erode the general prohibition of homicide, it could be taken to be a fourth possible bad consequence of euthanasia.

BROCK’S RESPONSE I• Because, according to Brock, stopping life support is killing the

patient in most cases, then permitting this kind of killing could already be seen to have weakened the prohibition of homicide.

• However, Brock recognizes that most people, as well as the courts, have not seen passive euthanasia as killing, and so it would not really figure in here as a weakening of the prohibition of homicide.

• Passive euthanasia has been thought acceptable on grounds of the rights to privacy and self-determination and has not been looked at as an exception to homicide laws, but Brock says that the same fundamental right of self-determination applies to euthanasia.

• After all, in euthanasia the patient consents to his killing, whereas in other cases of homicide he does not.

BROCK’S RESPONSE II

• Both murder and euthanasia are kinds of homicide, kinds of deliberate killing of one innocent human by another. However, they differ in that, in euthanasia but not in murder, the person who is killed gives his consent to be killed. Thus there is self-determination in euthanasia but not in murder.

• And Brock says that “If procedures can be designed that clearly establish the voluntariness of the person’s request of euthanasia, it would under those procedures represent a carefully circumscribed qualification on the legal prohibition of homicide.”

ABUSE OF A GOOD THING• The final potential bad consequence of permitting

euthanasia even for those cases “in which it is unequivocally voluntary and the patient finds his or her condition unbearable,” is that euthanasia would inevitably lead to abuse in being performed in cases where patient consent is not given and may not be desired.

• This is the slippery slope argument which says that people will abuse a good thing, and because active voluntary euthanasia will lead to nonvoluntary and even involuntary euthanasia, it should not be permitted in any case.

BROCK’S RESPONSE I

• Although Brock thinks that this objection is the most serious objection to euthanasia, he also thinks that the strength of such slippery slope arguments can be doubted and are hard to evaluate.

• When all else fails, the conservative objector to euthanasia simply says that it will end up being applied to people who have not asked for it, and because it will end up being so applied it should not be legalized in the first place.

BROCK’S RESPONSE II

• For Brock, whereas one must admit that abuses of euthanasia are possible, that is not enough to prohibit it if it is otherwise morally justified.

• What has to be assessed is how likely the abuses are.

• Euthanasia would be abused if the conditions for granting euthanasia to a patient are not satisfied.

• Most specifically, if the patient’s consent has not been given, or if her consent has been forced through persuasion.

BROCK’S RESPONSE III• However, unless opponents of euthanasia can

provide good data to support their view of likely abuses there is little reason to consider them.

• The extent to which abuses are likely depend on the rules and procedures which are put in place to prevent such abuses from occurring.– [See Brock’s four guidelines to avoid abuses on p. 196.]

• The idea of the safeguards is to ensure that it is the patient who makes the choice, and the choice is informed by accurate medical information.

BROCK’S RESPONSE IV

• At the same time that we want rules which will help to avoid abuses, we do not want to make them so strict that voluntary active euthanasia will be impossible to get for someone who wants it.

• Life is such that some abuses are likely to occur, but abuses can be minimized by ongoing reviews of cases of euthanasia which have occurred.

NONVOLUNTARY ACTIVE EUTHANASIA I

• Brock thinks that a system can be constructed where it will make involuntary active euthanasia rare or unlikely, but he says that legalization of voluntary active euthanasia could very well make nonvoluntary euthanasia likely.

• Thus, where we cannot get a patient’s consent, due to coma for instance, we may be tempted to legalize nonvoluntary euthanasia.

• Here the right to choose euthanasia would be given to a person who can act on behalf of the patient - such as a family member. And the person who chooses for the incompetent patient is supposed to choose as the patient would have chosen if able to do so.

NONVOLUNTARY ACTIVE EUTHANASIA II

• The reasoning behind allowing nonvoluntary euthanasia is that it seems “unreasonable to continue life-sustaining treatment that the patient would not have wanted just because the patient now lacks the capacity to tell us that.”

• As it is now, patient surrogates will often refuse life-sustaining treatment when they know that is what the patient would have wanted, and such a wish could extend from voluntary to nonvoluntary euthanasia.

• As Brock says, “why continue to force unwanted life on patients just because they have now lost the capacity to request euthanasia from us?”

NONVOLUNTARY ACTIVE EUTHANASIA III

• Of course, the courts can still restrict euthanasia to voluntary only, as they have in Holland.

• Nonvoluntary euthanasia can be fairly clear cut where a patient has made her wishes known ahead of time, but, for those who have not, Brock says that the potential for abuse is clearly there if nonvoluntary euthanasia is legalized.

• Thus for nonvoluntary euthanasia the important thing for avoiding abuse is to make sure that rules are in place for surrogates acting on behalf of incapacitated patients.

NONVOLUNTARY ACTIVE EUTHANASIA IV

• Rules which are in place which authorize others to act on the patient’s behalf when the patient herself has given such authorization can protect us from sliding down the slippery slope from voluntary to nonvoluntary euthanasia.

• Brock ends by saying that the issues concerning euthanasia are complex, but he thinks that the arguments in favor of permitting it are stronger than the arguments against it.