Course notes for students of the Edexcel syllabus on Medical Ethics Part 2: end of life issues – Course notes and revision materials for students of A Level Religious Studies/Philosophy.

From the Paper 2 syllabus for Religion and Ethics:

6.1 Issues in medical ethics with a focus on beginning and end of life debates (4)

b) Assisted dying, euthanasia, palliative care. Religious and secular contributions to all these issues, legal position, concepts of rights and responsibilities, personhood and human nature, options and choices.

With reference to the ideas of P Singer and J Glover

*You Don’t Know Jack* is an HBO drama examining the role of Dr Jack Kevorkian in making physician-assisted suicide possible in the USA. It is especially relevant when it comes to the case of ‘Margo’ (see below) as Kevorkian is depicted helping to facilitate the death of one Alzheimers patient.

Euthanasia : Definitions

The term ‘euthanasia’ means ‘easy death’ but more usually and typically describes usually describes doctor assisted suicide.
Doctors may help a patient to die who has requested assistance in ending their life by giving them a lethal injection or an overdose of barbiturates. This is known as voluntary euthanasia.
Alternatively, if the patient is ‘brain dead’ (i.e. in a persistent vegetative state), is simply too young to request assisted suicide (e.g. as in the case of a newborn baby), or is otherwise incapable of understanding their situation (e.g. due to old age or illness) other methods to facilitate the premature death of a patient might be employed e.g. switching off a life-support machine or withholding medical treatment that would otherwise prolong life. This is known as nonvoluntary euthanasia.
From the above examples we can see that euthanasia can also be active and passive. Euthanasia is active when the doctor actually performs an action which results in the death of the patient e.g. administers an overdose of painkilling medication that will result in the death of the patient; it is passive when a decision is made by medical staff to no longer provide medical treatment that would otherwise keep the patient alive.
There is also involuntary euthanasia. This describes circumstances when someone is killed who has not consented to this action being performed e.g. Jewish victims of the Nazis did not consent to being murdered in the gas chambers where the Final Solution was carried out.

Religious Approaches to Euthanasia

NOTE: the teachings mentioned in this section are meant to apply to all forms of euthanasia not just voluntary euthanasia.

Biblical Teachings

Here the teachings about the Sanctity of Life that we looked at in connection with abortion also apply. So you should refer to the relevant section of your course notes on abortion when you revise this topic.
In addition, the Old Testament book of Job chapter 1, verse one says that, ‘Naked I came from my mother’s womb and naked shall I return there; the Lord gave, and the Lord has taken away.’
Traditionally, this passage has been understood to mean that God is the giver of life and that life is a gift. It is therefore up to Him when it should start and finish. A person does not have the freedom to decide to end his own or anyone else’s life.
In 1 Corinthians chapter 3 verse 16, St Paul, an early Christian convert, compares the human body to a temple, a sacred building. Christians might use this passage to show that the body should be treated as a place where God lives, and should be respected, not killed through an act of euthanasia.

Church Teachings about Euthanasia

The Roman Catholic Church is against euthanasia, seeing it in the same light as murder.
In the 1968 Papal encyclical (a letter sent to all Catholic bishops) Humanae Vitae, Pope Paul VI emphasized that ‘human life is sacred’. However, it is not regarded as an ex cathedra expression of papal infallibility that has to therefore be accepted by all Catholics.
According to the Catechism of the Catholic Church (a summary of the main Catholic teachings) ‘We are stewards, not owners, of the life God has entrusted to us. It is not ours to dispose of.’
The Catholic Church would, nevertheless, support starting a patient on a course of pain-killing drugs which may eventually lead to the patient’s death. The intent has to be to reduce pain, however, according to the principle of double-effect.
However, 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. Dr George, a London Consultant in Palliative Medicine, has commented: ‘Doctors in palliative care are never faced with the dilemma of controlling severe pain at the risk of killing the patient. They manage pain with drugs and doses adjusted to individual patients so that they can be comfortable and able to live with dignity until they die. It is most regrettable that the truth about morphine’s safety and efficacy never appears in the general press while claims about the so-called double effect, euthanasia and doctors “killing” with morphine automatically do.’
George and Regnard have also highlighted the erroneous linkage between morphine and the so-called ‘Double Effect’, with George adding: ‘When correctly used to relieve pain in a patient who is terminally ill, morphine like drugs should never cause death. By contrast they may well lengthen life and certainly improve its quality.’
SEE HERE FOR MORE ON THE USE OF MORPHINE IN PALLIATIVE CARE AND ITS RELATIONSHIP TO THE PRINCIPLE OF DOUBLE-EFFECT.
The Catholic Church also believes that ordinary treatments (such as feeding a patient) may not be discontinued, but extraordinary measures (like complicated operations) need not be undertaken to save the patient’s life.
The Church of England also disagrees with euthanasia. They echo the Roman Catholic Church in their belief in the sanctity of human life. However, they also teach that it is not always right to strive to keep a patient alive for as long as possible regardless of their quality of life.
However, not all Christian theologians agree with these teachings.
For example, Hans Kung, a Catholic priest and theologian said: ‘…I am convinced that the all-merciful God, who has given men and women freedom and responsibility for their lives, has also left to dying people the responsibility for making a conscientious decision about the manner and time of their deaths.’
In other words, he is arguing that since God gave us free-will, we should be allowed to make a responsible and careful choice of our own about whether we carry on living or not.

Situation Ethics

The Situation Ethicist Joseph Fletcher also disagreed with traditional Christian teaching about euthanasia.
Situation Ethics is personal – it puts people before rules. So legalistic rules and deontological religious teachings forbidding euthanasia may, in some circumstances, be dispensed with, if the most loving thing to do is to give someone a peaceful death.
It is also pragmatic and relativistic, allowing us to do whatever works best in the circumstances, as when there may be no use in keeping someone alive if they are suffering unbearably.
A situationist would probably say that, even if euthanasia was illegal, it may well sometimes be right to break the law and help someone to die.
Situationists might, nevertheless, be worried that a law that allowed voluntary euthanasia could put pressure on people who didn’t want to die. An example might be elderly people in poor health who no longer wished to be a burden on the relatives caring for them.
They might therefore argue that there need to be robust safeguards against the misuse of any euthanasia rules.
Joseph Fletcher himself supported the view that a person may have a right to die because, for a Christian, death is not the end, and ending a life of great pain might be the most loving thing to do. This is because Fletcher thought that the quality of a person’s life was more important than the sanctity of life, and that to keep someone alive when they are suffering and in great pain was purposeless, demoralizing and degrading.

Secular Approaches to Euthanasia: Ronald Dworkin

See the previous notes on beginning of life issues where Dworkin’s views are introduced.
Dworkin believes 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.
For Dworkin, those who disagree about euthanasia 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 be completed. 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 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.’

Hospices and Palliative Care

For those that support them, Hospices provide an alternative to voluntary euthanasia and help people to die with dignity.

How did the Hospice Movement begin?

Late 1900s: A group of Irish nuns, Sisters of Charity, set up a home in Dublin to care for the dying.
1900: Five of the nuns travel to the East End of London and continue the work.
1967: Cicely Saunders, a doctor, helped to create St. Christopher’s Hospice in London, one of the most famous.
Now: There are over 150+ adult hospices in England alone. At any one time, they care for 2000+ patients. Hospices are not just for Christians, and not everyone who works there is a Christian. They do not try to make anyone believe in God, but provide opportunities to talk to ministers / priests if the patient wants. Hospices support relatives, even after the patient has died. Some Hospices are for children, with facilities for children and families, with play areas, gardens, and rooms for brothers and sisters to stay.

The aims of the Hospice Movement

Hospices provide care and support for patients, relatives and friends at the most difficult stage in their lives. Hospices aim to

Relieve pain – whether caused by the illness or by the stress and fear it creates. Hospices specialise in pain control and lead the way in palliative medicine (pain control by drugs). They say all pain, no matter how severe, can be brought under control.
Enable patients, families and friends to face up to death by allowing them to talk a free and open way. This is one of the main facilities offered by Hospices.
Care for the emotional needs of relatives – before, during and after the patient’s death. In most hospitals, the needs relatives are largely ignored. Hospices seek to fulfil those needs.

However (and this is a very important point), Peter Singer has questioned the effectiveness of palliative care.
In the latest edition of his book, Practical Ethics, he writes the following:

‘…some will reply that improved care for the terminally ill has eliminated pain and made voluntary euthanasia unnecessary. But it is not only physical pain that makes people wish to die : they may suffer from bones so fragile they fracture at sudden movements, uncontrollable nausea and vomiting, slow starvation due to a cancerous growth, inability to control one’s bowels or bladder, difficulty in breathing, and so on. These symptoms often cannot be eliminated, at least not without keeping the patient unconscious all the time.’

The Situation Ethicist, Joseph Fletcher, in a publication called Moral Responsibility: Situation Ethics at Work, gives a moving description of a minister visiting a woman in her seventies who is in hospital with bone cancer and suffering from one of the conditions that Singer mentions:

‘Both legs were already fractured when she arrived at the hospital and little bits of her bones are splintering all the time; she has agonizing shaking attacks that break them off. She turns away from her clerical caller and looks at her husband. ‘I ought to die. Why can’t I die?’

However, more than fifty years before the publication of the newest edition of Practical Ethics, Cicely Saunders had this to say in the Medical Journal The Lancet, in 1961: ‘We are now always able to control pain in terminal cancer in the patients sent to us and only very rarely indeed do we have to make them continually asleep in so doing…I certainly agree…that there is much suffering among the dying in this country, but, without going into the reasons why I [personally think that euthanasia as advocated is wrong, I would like to emphasize again that it should be unnecessary and is an admission of defeat.’
See also the observations made by Rob George and Claud Regnard (above).
However, it should be noted that Saunders is only referring to the treatment of cancer patients here and – like Singer – focuses only on the physical symptoms of terminal illness, thus overlooking the profound psychological distress that end-stage medical conditions and even non-fatal disorders, like tetraplegia or locked-in syndrome may elicit in patients.

Is nonvoluntary euthanasia morally acceptable?

When a human being is incapable of understanding the choice between life and death, euthanasia would normally be nonvoluntary.
Those unable to give consent would include incurably ill or severely disabled infants, and people who through accident, illness or old age have permanently lost the capacity to understand the issue involved (perhaps due to dementia/Alzheimer’s disease), without previously having requested or rejected euthanasia in these circumstances.
Examples of severe disability in children include anencephalic infants (infants born without major parts of the brain, skull and scalp); infants who have, usually as a result of extreme prematurity, suffered such severe bleeding in the brain that they would never be able to breathe without a respirator or recognise another person; and infants lacking a major part of their digestive tract, who could only be kept alive by means of a drip providing nourishment directly into the bloodstream.
Even ex-US President Ronald Reagan’s surgeon general, someone who, like Reagan, seemed to have been a firm believer in the sanctity of life, thought that life sustaining treatment for children born with these conditions was not appropriate.
An example of people who have lost the capacity to understand the issue involved would be those in a persistent vegetative state (known as PVS). Such cases are not rare. Many hospitals care for motor accident victims whose brains have been damaged beyond all possible recovery. They may survive, in a coma for many years. Estimates of the number of people in a state of PVS in the USA at any given time vary from 10,000 to 40,000.
Improved imaging techniques have enabled us to see that for many people in this state, there is no blood flow to the parts of the brain responsible for consciousness. Without blood flow the brain rapidly decays, and so the existence of consciousness, or the possible recovery of it, can definitely be ruled out.

Religious Responses to nonvoluntary Euthanasia

As was the case with voluntary euthanasia, the teachings on the sanctity of life apply, as does the primary precept in Natural Moral Law theory about the preservation of life.
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.

Peter Singer on nonvoluntary Euthanasia

Singer is typically consistent on this issue, and again draws on the principle of personhood in outlining his views.
For Singer, ‘killing a disabled human infant is not morally equivalent to killing a person’, because such an infant is not aware of itself as an individual with a life of its own to lead. This is especially not wrong in cases where the child may be physically suffering with no prospect for that suffering ever being relieved.
However, as a preference utilitarian, Singer does acknowledge that some parents may want even the most gravely disabled infant to live as long as possible, and that their preference should count as a reason against killing the infant.
He further acknowledges that some couples may be willing to adopt a severely disabled child, though he states that this usually happens as a result of publicity, while the more common situation is one in which the child ends up in an institution because the parents feel unable to cope.
Adoption may also be a possibility in the case of children born with less severe problems, such as haemophilia and possibly Down’s Syndrome.
Nevertheless, he still that because a newborn infant is not a person, that this can make infanticide morally acceptable.
Singer also thinks that it may be acceptable for people in a vegetative state, and people who in advanced old age have lost their sense of personhood.
He argues that for people who do not wish to be subjected to nonvoluntary euthanasia under any circumstances, a system whereby they could officially register that preference could be introduced.
Additionally, Singer argues against the distinction between active and passive euthanasia, which is consistent with his wider rejection of what is known as the acts/omissions doctrine (see below for more on this).
As both types of euthanasia typically result in the death of the person, 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.’
He therefore believes that active euthanasia is more humane.
Again this view is absolutely consistent with his views about abortion. At the point where the fetus might be able to feel pain (roughly about the 18 week stage of gestation), the method used to abort the fetus should be as painless as possible, because even though a fetus is not a person the fact that it can experience pain should be taken into consideration. Similarly, active euthanasia might relieve pain more quickly in cases where the patient has lost their sense of personhood, but perhaps not their capacity to experience pain.

Jonathan Glover on nonvoluntary euthanasia

Glover’s secular views have also previously been described in the course notes on beginning of life issues. He considers the taking of human life to normally be directly wrong when someone is deemed to be living a worthwhile life that they are capable of appreciating as such. Glover additionally observes that killing someone is objectionable if it overrides someone’s preference for staying alive, noting that this does not apply to new born babies who cannot be considered capable of having any preference for life over death. Whilst agreeing that infanticide may sometimes be right when the quality of the newly born child’s future life is thought to be low, Glover advocates ‘the working-out of a social policy with great explicitness and detail’, in anticipation of any pressures ‘to extend the scope of infanticide once it is made legitimate at all. ‘ Here he thinks it sensible to trust any consensus that emerges among those with the relevant knowledge and experience e.g. parents of severely affected children and doctors specializing in the field.
Glover notes that there are also adults ‘whom we think may have lives worse than death but who are not in a position to express any decision of their own on this…They may be so senile that they cannot understand the question, or totally paralysed, or…blind and deaf, and so out of communication with us.’
He acknowledges that ‘there is no adequate test for deciding the point at which someone’s life is not worth living’ and suggests that ‘the least unsatisfactory test is to ask what one would choose for oneself: would I choose death rather than have that sort of life?
Glover’s appeal to preferences here is complicated by the case of Margo as described by Ronald Dworkin (see below).

Is voluntary euthanasia morally justifiable?

Background

Many cultures have considered suicide, in certain circumstances, to be rational, honourable, and even sometimes a noble act.
For example, the Stoic philosopher Seneca wrote that a wise person ‘lives as long as he ought, not as long as he can.’
And the samurai warriors of Japan regarded ritual disembowelment, an action known as seppuku or hara-kiri to be a noble act in certain situations.
However, most people seeking voluntary euthanasia require the assistance of a medical practitioner to help them. But since the fifth Century BC, when they first took the Oath of Hippocrates and swore ‘to give no deadly medicine to anyone if asked nor suggest any such counsel’, euthanasia has been widely rejected by doctors.
Nevertheless, at the present time, doctor assisted suicide is illegal in the UK but is permitted under strictly controlled conditions in Holland, Belgium, Switzerland, Luxembourg and the US states of Oregon, Washington and Montana.
In the Netherlands, a series of court cases during the 1980’s upheld a doctor’s right to assist patients to die.
The courts did not distinguish between providing a patient with a prescription for a lethal dose of a drug and giving a patient a lethal injection. In fact, in the Netherlands, most doctors think it is better that a physician is present when the patient dies to make sure that nothing goes wrong. Injections tend to be preferred when a patient is unable to swallow, or keep down, a large dose of a drug.
The Dutch parliament did not actually legalize euthanasia until 2002, although for the previous 20 years, doctors were not prosecuted if they followed certain guidelines that had been developed. These guidelines then became part of the law.
So in the Netherlands, euthanasia is lawful only if a) It is carried out by a doctor ; b) the patient has requested euthanasia in a manner which leaves no doubt that their decision is voluntary, well-informed and well-considered; c) the patient has a condition which causes them profound and prolonged mental and physical suffering that they find unbearable; d) there is no reasonable alternative (reasonable from the patient’s point of view) which might help to alleviate their suffering and e) the doctor has consulted another independent professional who agrees with his or her judgement.
Opponents of the legalization of voluntary euthanasia object to it for several reasons.
They have argued that it represents the first step down a slippery slope. For example, we might start with euthanasia only for the severely and chronically sick, but before long people who are socially unproductive might be included, or people from an unwanted racial minority, so that eventually we slide into an abyss of state terror and mass murder, as happened in Nazi Germany.
The Swiss organisation, Dignitas, are frequently mentioned as an example of the slippery slope phenomenon at work. Dignitas is a charity founded in 1998 that allows people to die with dignity. Under Swiss law, assisted suicide is a crime only if those who provide assistance can be shown to have acted out of self interest.
In January 2003, Reginald Crew, 74, who had motor neurone disease, became the first Briton to publicly travel to the country to kill himself at the clinic. Merseyside police announced that his wife, Win, would not be prosecuted for helping him.
However, there has been considerable concern about this Charity in the UK because British people have made use of the Dignitas service who were not terminally ill. Critics of Dignitas have claimed that the organisation promotes ‘suicide tourism’.
For example, Daniel James, 23, who had played rugby for England as a teenager, died at the Dignitas clinic in September 2008 after becoming paralysed from the chest down in a rugby training accident. West Mercia police initially investigated his death but three months later the director of public prosecutions announced that no action would be taken against his parents as it was not in the public interest “although there was sufficient evidence for a realistic prosecution”. His parents said Daniel, a tetraplegic, felt his body had become a prison and he lived in fear and loathing of his daily life. His death sparked widespread debate as he was not suffering from a life-threatening condition.
In 2009, one of Britain’s most respected conductors, Sir Edward Downes, and his wife Joan, ended their lives together at the clinic. Sir Edward, 85, who was knighted in 1991, was almost blind and his 74-year-old wife was his full-time carer. He had a long and distinguished career with the BBC Philharmonic and the Royal Opera House, and conducted the inaugural performance at Sydney Opera House. The couple’s children, Caractacus and Boudicca, said their parents had “died peacefully, and under circumstances of their own choosing”.
This raises another important issue: should people who are suffering from painful and incurable diseases that are not terminal also be allowed to end their lives?
For further evaluation of the ‘slippery slope’ concern when it comes to the legalization of euthanasia, see HERE.

Jonathan Glover on voluntary euthanasia

Glover states that ‘it may in a particular instance be right to provide the help needed for suicide’ and that ‘if assisted suicide is possible, it is always to be preferred to voluntary euthanasia’ as this preserves the principle of autonomy that he values so highly. Additionally, he writes that, ‘If we know that a person himself knowingly took a lethal pill, there is by comparison with euthanasia little ambiguity about the nature of his decision…But where the person does not perform the final act himself, there is always more room for doubt about the extent to which he desired death.’
Glover acknowledges that a request for euthanasia may not always be an expression of a carefully considered decision and that a ‘thorough discussion, repeated on several occasions ‘ would be required so as to ‘form a better impression of the person’s preferences’ and to ensure that the decision is an informed one e.g. that it is not being made because the patient has formed an exaggerated view of the pain involved in a particular illness.
He further argues that concerns about the legalization of euthanasia could be mitigated by looking at how it is practised in other countries. The law here might then be modified for a trial period in order that the consequences of such a change might then be assessed.

Jonathan Glover and Peter Singer on the Acts/Omissions doctrine

Glover devotes a chapter of Causing Death and Saving Lives to a discussion of “the acts and omissions doctrine,” that is, the view that in certain situations, it is less bad, morally, to omit to do an act than it is to perform a different act, even though the act and the omission have identical consequences. “It will be
argued here,” Glover writes, “that we ought to reject the acts and omissions doctrine.”
An illustration of the doctrine is provided in a poem by A.H. Clough quoted by Glover: ‘Thou shalt not kill but need’st not strive, Officiously to keep alive.’
When it comes to active and passive euthanasia, the principle is often appealed to in an attempt to demonstrate that there a genuine moral difference between an act (e.g. deliberately ending the life of a patient) and an omission (withdrawing treatment so that a patient eventually dies), with the former being perceived as morally worse.
Glover himself gives a striking further illustration of the doctrine: an omission on the part of the government to raise the old age pension sufficiently to prevent a number of those who receive it from being able to afford enough heating during the winter leading to them dying from cold is not usually thought to be nearly as bad as the Chancellor taking a machine gun to an old people’s home in order to kill the same number of people. In other words, the distinction the doctrine makes between an act and an omission is one that most of us consider to be morally persuasive at an intuitive level.
Glover also notes the argument that abandoning the acts and omissions doctrine would be intolerably burdensome, because: ‘It is arguable that we would have to give money to fight starvation up to the point where we needed it more than those we were helping: perhaps to the point where we would die without it. For not to do so would be to allow more people to die, and this would be like murder.’
Nevertheless, Glover still argues that we should reject the doctrine.
Amongst the many criticisms that Glover refers to in doing so (that are too detailed to be treated in depth for the A Level course), one that is easy to remember and worthy of further discussion is this: ‘It is arguable that indifference plays as large a part as in causing the world’s misery as positive hostility. The existence of wars, poverty and many of the other things that destroy or stunt people’s lives may be as dependent on widespread unconcern as on any positively bad motives. It may well be because of tacit acceptance of the acts and omissions doctrine that we acquiesce in the worst evils in the world.’
Commenting on this passage, Peter Singer has written that ‘This is a plausible claim. But it adds to the puzzle of why the only omissions Glover discusses in Humanity [one of his later books] are the inadequacies of the bystanders to the Holocaust, while the “widespread unconcern” of most of the citizens of the affluent world about the avoidable poverty-related deaths of tens of millions of people are themselves omitted from the book. Other things being equal, I can see no adequate grounds for giving a higher priority to stopping genocide than to stopping poverty-related deaths. Recognizing the serious nature of our failure to aid those dying from poverty-related causes. by giving the topic at least one chapter in Humanity, would have been a good way of making this point, and would not have run the risk of superficiality.
In other words, in adopting a broadly utilitarian position that entails rejecting the acts/omissions doctrine, both Glover and Singer acknowledge the additional burden of moral responsibility that follows from this, with Singer going further than Glover in doing so.
For more on Singer’s further development of his stance on world poverty and our responsibilities to others, see this compelling video.

Ronald Dworkin and Dementia

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.
Preference utilitarianism (an influence on both Singer and Glover) might be difficult to apply to this situation. 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?
All in all, the case of Margo might therefore be an interesting one to discuss if an examination question permits the scope to do so.
In addition to stating the patient’s preferences about future treatment if they lose the ability to make decisions, it is worth mentioning that living wills might also include the nomination of someone to make those decisions for them.

EXTENSION MATERIAL : Voluntary Euthanasia and the case of Eva

NOTE: THIS DOCUMENTARY IS POWERFUL AND UPSETTING, SO DO BEAR THIS IN MIND BEFORE VIEWING IT.

End Credits is a documentary about euthanasia in Belgium. Sections of it follow the story of Eva, 34, who is described as suffering from ‘chronic, incurable, psychiatric illness’ (probably suicidal depression) who requests euthanasia because nothing she has tried has helped.

The case of Eva raises the issue of whether doctor-assisted suicide should be extended to patients with severe mental health problems. It also touches on something known as the ‘slippery slope’ argument, which suggests that when euthanasia becomes legal for the worst kind of terminal illness, such as motor neurone disease, that it will eventually be made available to patients with less serious problems and issues, which could still be treatable.

In the documentary, Eva is presented as someone who has tried all the available treatments, though only one is specifically mentioned.

Supporters of voluntary euthanasia might believe that Eva should be put out of her mental misery if the doctors and psychiatrists agree with this decision. If she hates life, if the quality of her life is so poor, why force her to carry on living? However, there are some new forms of counselling and therapy that may prove to be effective when it comes to suicidal depression, such as Cognitive Behavioural Therapy (CBT) and Mindfulness Based Cognitive Therapy (MBCT). So the viewer is left wondering whether these were ever made available to Eva, and at what point a patient like her deserves to be labelled as ‘incurable’.

MBCT has been approved for use by the National Institute for Health and Clinical Excellence in the UK. Two randomized clinical trials have pointed to its efficacy in reducing rates of relapse by 50% in patients who suffer from recurrent depression

The case of Eva also highlights what is known as the ‘slippery slope’ issue in medical ethics. The slippery slope argument claims that the acceptance of certain practices, such as abortion on demand, doctor-assisted suicide or voluntary euthanasia will invariably lead to the acceptance of practices that are morally unacceptable e.g. allowing abortions for trivial/frivolous reasons (perhaps illustrated by aborting fetus’s with cleft palates) and euthanasia for, say, non-terminal mental health issues (as demonstrated by the case of Eva). Thus, it is argued, in order to prevent these undesirable practices from occurring, we need to resist taking the first step.

This is an issue which is discussed in connection with the fourth anthology (see above for the relevant link). But for the moment, consider this version of a slippery slope argument:

Eating Ben & Jerry’s ice cream will cause you to put on weight. Putting on weight will make you overweight. Soon you will weigh 350 pounds and die of heart disease. Eating Ben and Jerry’s ice cream leads to death. Don’t even try it!

Does the above indicate that fears of a descent down a slippery slope are exaggerated or groundless? Or does the case of Eva provide evidence that those who have expressed concern about the consequences of legalizing voluntary euthanasia or doctor-assisted suicide are correct to do so?