Taken from: Issues of Life and Death by Michael Wilcockson (Hodder, 1999), Chapter 4, Euthanasia and Doctors’ Ethics, pp.56–69.
NOTE: Copyright issues may come into play at this point. So what you will find below are the FIRST and LAST couple of sentences of the section that is commented on followed by the commentary itself (though sometimes entire passages are quoted). If anyone finds this commentary useful, feel free to cut and paste the text of Issues of Life and Death and combine it with these notes.
The full extract can be found HERE
NOTE : THERE IS CONSIDERABLE OVERLAP WITH AND REPETITION OF MATERIAL ALREADY INCLUDED IN THESE COURSE NOTES.
Additional note: it is not often that I will seek to register a criticism of the Edexcel board themselves but it has to be said that this is an especially turgid and opaque piece of writing. Why it was chosen over much clearer contributors to the same field (Peter Singer and Mary Warnock spring immediately to mind) is mystifying.
- Good or bad medical practice?
A ‘third party’ in law refers to any agent other than the principal agent and in the case of euthanasia this would generally mean a doctor (sometimes also referred to as the ‘physician’)……Whilst the moral basis for sustaining life and allowing death is in transition, the medical profession and legislators will continue to inspire strong reactions.
Ronald Dworkin and Dementia
Dworkin was an American academic who specialized in the Philosophy of Law. The following case also illustrates how modern ethical decision-making can become tricky when it comes to medical ethics.
- In his book, Life’s Dominion, Dworkin discusses the case of ‘Margo’, a 54 year-old Alzheimer’s victim that was first described by a doctor called Andrew Firlik who met her when she was a medical student.
- According to Firlik, with each arrival, Margo behaves as if she knows him, though without ever using his name. She says she reads mysteries, but Firlik notices that “her place in the book jumps randomly from day to day . . . . [S]he feels good just sitting and humming to herself . . . nodding off liberally, occasionally turning to a fresh page.” She takes abundant pleasure in simple acts, such as eating peanut-butter-and-jelly sandwiches. Firlik writes that“despite her illness, or maybe somehow because of it, Margo is undeniably one of the happiest people I have ever known.”
- Dworkin raises the issue of whether, if Margo had signed an advanced directive stating that she should not receive treatment for any serious, life-threatening disease that she might contract after Alzheimer’s had rendered her demented, whether that directive should be honoured, given that she is not actually suffering?
- Dworkin controversially argues that the decision made when Margo was mentally competent should still be honoured by those who are responsible for caring for her, even though in her presently demented state, she seems to be capable of enjoying life, and might continue to do so if she was treated for any serious illness she might develop.
- Note that Dworkin’s conclusion might be different from that of a Benthamite act utilitarian, especially if Margo’s relatives and carers are of the view that she seems happy in her present state.
- And Singer’s preference utilitarianism might also be difficult to apply. Whose preferences should be honoured, those of Margo in her present state or those of Margo when she was mentally competent? Perhaps Singer might say that the present Margo has lost something of her original personhood, causing him to side with Dworkin.
- There is also Kant to consider. Is Margo to be considered a former member of his Kingdom of Ends as she is no longer fully rational?
Ronald Dworkin on the Sanctity of Life and Euthanasia
- Unlike Singer, Dworkin suggests that there can be a secular, non-religious understanding of the concept of the sanctity of life, according to which human beings are regarded as the highest product of evolution, so that human life can be seen as intrinsically important even from this perspective. So the concept is not out of date.
- For Dworkin, those on both sides of the euthanasia debate have tended to lose sight of the common ground that exists between them on this point.
- For him, the issue is therefore not whether the principle of the sanctity of life should yield to some other value, like humanity or compassion, but how life’s sanctity should be understood and respected.
- He writes that ‘making someone die in a way that others approve, but he believes a horrifying contradiction of his life, is a devastating, odious form of tyranny.’
- On the other hand, for others, ‘the struggle to stay alive, no matter how hopeless or how thin the life, expresses a virtue central to their lives, the virtue of defiance in the face of inevitable death.’
- Dworkin therefore thinks that the laws we make about euthanasia should reflect the patient’s right to self-determination as an expression of the sanctity of their own individual existence, when it comes to deciding how their life should end. In other words, the law should be flexible enough to allow them to end their lives with dignity if they wish, whilst allowing others to fight on until the end if that is what they want to do.
- In addition, the state should ‘encourage people to make provision for their future care themselves’. By this Dworkin means that the government should prompt people to make it known what their wishes would be should they, for example, become terminally ill or involved in an accident which renders them brain dead.
- In cases where no prior wish has been expressed, he thinks ‘the law should so far as possible leave decisions in the hands of their relatives or other people close to them, whose sense of their own best interests…is likely to be much sounder than some universal, theoretical, abstract judgement born in the stony walls where interest groups manoeuvre and political deals are done.’
Three Moral Principles
Three principles presuppose that the doctor is working from the traditional SOL position enshrined in the part of the Hippocratic Oath which states ‘I will give no deadly medicines to anyone if asked, nor suggest any such counsel’ (BMA Handbook, p.69).….. Morally if they engage in treatment and then decide to withdraw treatment on the grounds that the baby will no longer have a worthwhile life, it may no longer be considered indirect killing but an act of active non-voluntary euthanasia or murder (See Singer, Rethinking Life and Death, 1994, pp.75-80 for examples and discussion.)
- Peter Singer argues against the distinction between active and passive euthanasia.
- As both types of euthanasia typically result in the death of the person, he notes that the consequences are the same.
- But when treatment is withheld, as in passive euthanasia (e.g. by not administering a course of antibiotics that might keep a patient with dementia alive), a lingering, painful death often results, while ‘nature takes its course.’
- Singer therefore believes that active euthanasia is more humane.
Another indirect argument has a long tradition in Natural Law ethics and involves two kinds of intention…..However, the term ‘euthanasia’ is resisted in the same way that ‘abortion’ is avoided for similar reasons. But is the DDE open to abuse?
• Is there a satisfactory distinction between intending and foreseeing? Might one say that the DDE is bad medicine, that if I foresee death but fail to act, then this is an omission which is a form of indirect euthanasia – which is rejected by the SOL?
Comments on the principle of double effect
- According to Aquinas’s principle of double-effect, an action may be permitted if: 1)the action is moral 2) the person doing it intends the main effect of the action to be good rather than bad and 3) there is another, unavoidably bad effect which also results from the same action.
- In cases of abortion, the principle of double effect might justify a Catholic doctor who is morally opposed to abortion performing an operation on a pregnant woman who will die if her cancerous womb is not removed or her ectopic pregnancy is not terminated. As long as the doctor intends to save the mother’s life and there is no other way to do so apart from having the operation the secondary effect (abortion) is allowable in these circumstances.
- However, our intentions are hidden from others and so this principle makes it possible for us to conceal what might be our malicious intentions from others.
- This may be particularly significant if the principle of double effect comes into play where euthanasia is concerned. For example, a doctor who wishes to prevent pain in a dying patient may give that patient a drug which the doctor knows will shorten the patient’s life. As long as the Doctor’s main intention is to relieve pain, the secondary effect (eventual euthanasia) is allowable.
More on the principle of double-effect
- Natural Law (as formulated by Aquinas) deals in moral absolutes – primary precepts that cannot be broken regardless of the situation.
- One of the primary precepts is to ‘protect and preserve the innocent’. It is therefore a secondary precept and an absolute moral rule that you should never kill an innocent person. It would seem that euthanasia is always wrong.
- However, we mustn’t forget the principle of double effect (which was formulated by Aquinas and was, in turn, adopted by Roman Catholic theology). It is wrong to kill, but is it wrong to give someone pain relief if a secondary effect is that they die?
- So while Natural Law clearly does not support active euthanasia, it may well allow an action whose intention is merely to relieve pain, even if the action leads to death.
- However, Peter Singer has criticised the reasoning behind the principle of double effect.
- He argues that if we foresee both effects then we must take responsibility for both of them.
- And he also argues that if we think that a person’s future quality of life may be so poor as to warrant relieving their suffering through an overdose of a painkiller then our decision is not really one based on the teaching of the sanctity of life. It is actually a utilitarian one based on what we think would be the consequences if we allowed the person to go on living in a state of unbearable suffering.
- In other words, when someone makes use of the principle of double-effect to justify their actions, they are actually behaving like a utilitarian in disguise.
- Additionally, two expert UK consultants in palliative care, Rob George and Claud Regnard have pointed out that ‘numerous studies and reviews of opioids and sedatives worldwide are clear that they do not hasten death or alter survival.’ So doctors should never need to have recourse to the principle of double-effect if they are competent and are administering an analgesic like morphine for the purpose of relieving pain in a terminally ill patient.
- The principle is also based on intention or motive that is hidden. So there is no way of telling whether a doctor giving pain relief is doing so for the right reason.
Ordinary and extraordinary means.
The principle of ordinary and extraordinary means is used both by weak SOL (WSOL) arguments and QOL proponents…..For instance, if a doctor withholds life-sustaining treatment, against his or her better judgement, but through respect for patient autonomy, the result might be condemned either as an act of professional negligence or wilful killing.
- WSOL = Weak Sanctity of Life QOL = Quality of Life
- Supporters of a weak sanctity of life stance realise that the advances of medical science have meant that the boundaries between life and death are far more flexible than previously thought and so would allow exceptions to the general sanctity of life position. If it is not clear what constitutes independent ‘life’ or when independent life begins then there may be certain situations in which abortion is morally justified. Christian proponents of a weak sanctity of life stance tend to balance the Bible’s pro-life teachings with Jesus’ emphasis on love and compassion as a justification for abortion in certain cases.
- In some cases, Christians might regard withholding treatment (passive euthanasia) and letting nature take its course to be morally acceptable, with the result that the patient dies. As no medical intervention takes place, the doctors and medical staff would not be ‘playing God’. For example, in Catholic teaching, using extraordinary measures to keep a patient alive is thought of as unnecessary, though there is some debate about where the lines should be drawn in this respect e.g. whether the use of a respirator represents an extraordinary treatment.
- In 2004, Pope John Paul II stated firmly that a feeding tube must not be withdrawn from patients in a vegetative state, saying that ‘the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act.’
- However, it is hard to see how the use of a feeding tube is not a medical act, given that inserting one is not something that people without medical training can do.
On the other hand, some argue that it is a doctor’s professional duty to use whatever medicines are available regardless of the situation.…In this case a doctor might then prescribe ‘nursing care only’ (the baby should be kept warm and fed) as proportionate to their needs, knowing that the baby will die shortly.
- For more on proportionalism, see your course notes on Natural Law theory and Bernard Hoose.
- Even ex-US President Ronald Reagan’s surgeon general, someone who, like Reagan, seemed to have been a committed Christian and firm believer in the sanctity of life, thought that life sustaining treatment for children born conditions like anacephaly was not appropriate.
The WSOL argues that where death is inevitable the doctor is bound by compassion or love to treat the patient accordingly. This attitude is summarised by the much quoted phrase, from Arthur Clough’s poem: ‘Though shalt not kill: but need’st not strive Officiously to keep alive’.…..For instance John Finnis’s ‘basic goods’ argument suggests a possible list of ‘valuable’ life criteria which include: play, aesthetic experience, sociability; but inevitably there is no agreement as to what these standards should be.
John Finnis is a modern theorist of Natural Law. Like Aquinas, he tries to identify a set of ‘basic goods’ (things that we all think are good) based on our natural inclinations. But as Wilcockson points out, the problem with Natural Law theory generally is that philosophers in this territory do not agree on what our natural inclinations are.
Law and Morality
So far the discussion has centred on the doctor-patient relationship within the constraints of law.…The BMA cites (Medical Ethics Today, p.153) the situation in the Netherlands where some 1000 (or 0.8 per cent) of all deaths a year are the result of non-voluntary euthanasia.
The figures for non-voluntary euthanasia in the Netherlands are not very reliable. First of all, non-voluntary euthanasia is illegal in the Netherlands, making evidence for its occurrence difficult to collect and substantiate. Secondly, the figures include the withdrawing of treatment from very premature or damaged new-born babies. Thirdly, the safeguards in the Netherlands euthanasia act are not as strict as those contained, for example, in the Death with Dignity act in the state of Oregon in the USA, where euthanasia is also legal. Stricter legislation could therefore, in theory, be drafted, that could serve to block any descent down a slippery slope e.g. it could specify precisely which conditions euthanasia might be permitted for. Finally, in her examination of the evidence supporting the claim that the Netherlands has already started its descent, Dr Penney Lewis has argued that there is none. There is nothing to back up the claim that non-voluntary euthanasia has increased because of the legalization of the voluntary, nor is there evidence from Oregon or Belgium.
Helga Kuhse challenges proponents of the wedge argument to provide empirical evidence to support their case. Her own conclusion is that the wedge argument is used by scaremongers to support their complete ban on all forms of euthanasia. The most frequently cited example of the wedge argument is the active non-voluntary euthanasia practised by the Nazis during the Holocaust years as a form of eugenics (literally ‘the production of good offspring’) where the deaths of millions were justified as part of the improvement of society. Kuhse concludes:
“…whilst the Nazi ‘euthanasia’ programme is often cited as an example of what can happen when a society acknowledges that some lives are not worthy to be lived, the motivation behind these killings was neither mercy nor respect for autonomy; it was, rather, racial prejudice and the belief that racial purity of the Volk required the elimination of certain individuals and groups. As already noted, in the Netherlands a ‘social experiment’ with active voluntary euthanasia is currently in progress. As yet there is no evidence that this has sent Dutch society down a slippery slope.”
-‘Euthanasia’, in P Singer (ed). Companion to Ethics (1991), p.302.
- In the Netherlands, a nationwide government commissioned study found that ‘many patients want an assurance that their doctor will assist them to die should their suffering become unbearable.’
- Often, having received this assurance, no request for euthanasia was then made. The mere availability of euthanasia brought sufficient comfort in itself without it then having to be provided.
- In fact, having observed the effects of the legalisation of euthanasia in Holland, Belgium and Luxembourg followed suit. Had there been any widespread abuses of the law, it is doubtful that these neighbours of the Dutch would have introduced similar laws.
The SOL deontological response is to point to a number of recent liberalisations in the law which illustrate the wedge taking effect. For instance, abortion in the UK is illegal but is permitted in extreme cases. Since 1967 (when the Abortion Act was introduced in England and Wales), the large number of abortions for 16–24-yearolds suggests that ‘exceptions’ (e.g. threat to psychological life of the mother) are effectively being used as a form of birth control. Many people now think that abortion is legal and in practice an abortion is usually given on demand. Another example might be the liberalising of the divorce laws and the decline of the family.
Mary Warnock argues against the analogy with abortion. As she puts it, ‘…this analogy is by no means exact, if only because before 1967 abortion was already widely and increasingly carried out by ‘back street’ practitioners, who caused many deaths. Indeed, part of the purpose of the new law was to bring this to an end by ensuring that abortions were performed only competently, and by those licensed to do so. There is a difference between attempting to control by regulation a practice that is widespread, increasingly in demand and dangerous, and attempting to permit a practice that that will arguably never be widely in demand. We hold that the case against euthanasia must be defended separately, and not built on a doubtful analogy.’
- Mary Warnock and Elisabeth MacDonald : Easeful Death – Is There a Case for Assisted Dying? P. 82
Finally, as we have already seen, there are those who argue that legalising euthanasia would not promote patient autonomy but in fact reduce it…..Thus many doctors fear that even a limited change in legislation would bring about a profound change in society’s attitude to euthanasia. By removing legal barriers to the previously ‘unthinkable’ and permitting people to be killed, society would open up new possibilities of action and thus engender a frame of mind whereby some individuals might well feel bound to explore fully the extent of these new options. Once previously prohibited action becomes allowed, the argument goes, it may also come to be seen as desirable – if not by oneself, then as something which might be recommended. A social environment which recognised the right to die, we argue, would bring about a fundamental shift in social attitudes to death, illness, old age and disablement. It would encourage the labelling of people by group and result in some groups who presented problems being seen as more expendable. It would also change the public view of the profession in an irrevocable way and undermine the trust that patients have in doctors.
- Medical Ethics Today (1993). P.151.
Sections of the above extract have been underlined in this version of the anthology extract because this issue has been partly addressed by Warnock and Macdonald as follows:
‘One of the fears most commonly expressed is that, if assisted dying were an option, patients in the last stages of their illness might have pressure put on them to ask for it, when it was not what they really wanted….There undoubtedly exist predatory or simply exhausted relatives. But it is insulting to those who ask to be allowed to die to assume that they are incapable of making an independent choice, free from influence…In any case, to ask for death for the sake of one’s children can [also] be seen as an admirable thing to do….Part of what makes a patient’s suffering intolerable may be the sense that he is ruining other people’s lives.
Additionally, Warnock and MacDonald point out that research has shown that ‘in both Oregon and the Netherlands, rates of assisted dying show no evidence of heightened risk for several vulnerable groups, notably the disabled, the elderly, and those with psychiatric illness.’
Finally, on the issue of the potential damage to the relationship of trust that exists between doctor and patient if euthanasia were to be legalized, Warnock and Macdonald comment as follows:
‘People often say that if physician-assisted dying were permitted in any form whatever, the trust between doctor and patient would be fatally eroded. It is alleged that patients who are ill, especially if they are otherwise vulnerable through age or disability, [would] fear to go into hospital, because they would never know whether the doctor is coming to their bedside to try to make them better or to kill them…On the other hand, there are patients who when they realize that that they have a condition that will be painful and may be terminal, say that they believe their doctor will ‘make it all right’. And by this they do not mean that the doctor will cure them, but that he will ensure that death, if it is to come, will not be too agonizing or long-drawn-out.’
- Mary Warnock and Elisabeth MacDonald : Easeful Death – Is There a Case for Assisted Dying? Pgs. 83, 88-89