Philosophy – Biomedical Ethics – Euthanasia

This is a short, formal compositions that calls upon you to engage critically with our readings and the issues. Remember, this is a philosophy assignment so make sure to answer the question fully. Make sure to fulfill both parts.

Analysis Essay Assignment:

Brock argues that there is no morally relevant difference between voluntary active euthanasia and physician assisted suicide. Present his argument for this claim as carefully as you can. Now criticize this argument, that is, demonstrate that it is either invalid or unsound.

VOLUNTARY ACTIVE EUTHANASIA
Since the case of Karen Quinlan first seized public attention fifteen years ago, no issue in biomedical
ethics has been more prominent than the debate about forgoing life-sustaining treatment. Controversy
continues regarding some aspects of that debate, such as forgoing life-sustaining nutrition and
hydration, and relevant law varies some from state to state. Nevertheless, I believe it is possible to
identify an emerging consensus that competent patients, or the surrogates of incompetent patients,
should be permitted to weigh the benefits and burdens of alternative treatments, including the
alternative of no treatment, according to the patient’s values, and either to refuse any treatment or to
select from among available alternative treatments. This consensus is reflected in bioethics scholarship,
in reports of prestigious bodies such as the President’s Commission for the Study of Ethical Problems in
Medicine, The Hastings Center, and the American Medical Association, in a Large body of judicial
decisions in courts around the country, and finally in the beliefs and practices of health care
professionals who care for dying patients.( n1)
More recently, significant public and professional attention has shifted from life-sustaining treatment to
euthanasia–more specifically, voluntary active euthanasia–and to physician-assisted suicide. Several
factors have contributed to the increased interest in euthanasia. In the Netherlands, it has been openly
practiced by physicians for several years with the acceptance of the country’s highest court.( n2) In 1988
there was an unsuccessful attempt to get the question of whether it should be made legally permissible
on the ballot in California In November 1991 voters in the state of Washington defeated a widely
publicized referendum proposal to legalize both voluntary active euthanasia and physician-assisted
suicide. Finally, some cases of this kind, such as “It’d Over, Debbie,” described in the Journal of the
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American Medical Association, the “suicide machine” of Dr. Jack Kevorkian, and the cancer patient
“Diane” of Dr. Timothy Quill, have captured wide public and professional attention.( n3) Unfortunately,
the first two of these cases were sufficiently problematic that even most supporters of euthanasia or
assisted suicide did not defend the physicians’ actions in them. As a result, the subsequent debate they
spawned has often shed more heat than light. My aim is to increase the light, and perhaps as well to
reduce the heat, on this important subject by formulating and evaluating the central ethical arguments
for and against voluntary active euthanasia and physician-assisted suicide. My evaluation of the
arguments leads me, with reservations to be noted, to support permitting both practices. My primary
aim, however, is not to argue for euthanasia, but to identify confusions in some common arguments, and
problematic assumptions and claims that need more defense or data in others. The issues are
considerably more complex than either supporters or opponents often make out; my hope is to advance
the debate by focusing attention on what I believe the real issues under discussion should be.
In the recent bioethics literature some have endorsed physician-assisted suicide but not euthanasia( n4)
Are they sufficiently different that the moral arguments for one often do not apply to the other? A
paradigm case of physician-assisted suicide is a patient’s ending his or her life with a lethal dose of a
medication requested of and provided by a physician for that purpose. A paradigm case of voluntary
active euthanasia is a physician’s administering the lethal dose, often because the patient is unable to
do so. The only difference that need exist between the two is the person who actually administers the
lethal dose–the physician or the patient. In each, the physician plays an active and necessary causal
role.
In physician-assisted suicide the patient acts last (for example,Janet Adkins herself pushed the button
after Dr. Kevorkian hooked her up to his suicide machine), whereas in euthanasia the physician acts last
by performing the physical equivalent of pushing the button. In both cases, however, the choice rests
fully with the patient. In both the patient acts last in the sense of retaining the right to change his or her
mind until the point at which the lethal process becomes irreversible. How could there be a substantial
moral difference between the two based only on this small difference in the part played by the physician
in the causal process resulting in death? Of course, it might be held that the moral difference is clear
and important–in euthanasia the physician kills the patient whereas in physician-assisted suicide the
patient kills him- or herself. But this is misleading at best. In assisted suicide the physician and patient
together kill the patient. To see this, suppose a physician supplied a lethal dose to a patient with the
knowledge and intent that the patient will wrongfully administer it to another. We would have no difficulty
in morality or the law recognizing this as a case of joint action to kill for which both are responsible.
If there is no significant, intrinsic moral difference between the two, it is also difficult to see why public or
legal policy should permit one but not the other; worries about abuse or about giving anyone dominion
over the lives of others apply equally to either. As a result, I will take the arguments evaluated below to
apply to both and will focus on euthanasia.
My concern here will be with voluntary euthanasia only–that is, with the case in which a clearly
competent patient makes a fully voluntary and persistent request for aid in dying. Involuntary euthanasia
in which a competent patient explicitly refuses or opposes receiving euthanasia and nonvoluntary
euthanasia, in which a patient is incompetent and unable to express his or her wishes about euthanasia,
will be considered here only as potential unwanted side-effects of permitting voluntary euthanasia I
emphasize as well that I am concerned with active euthanasia, not withholding or withdrawing
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life-sustaining treatment, which some commentators characterize as “passive euthanasia.” Finally, I will
be concerned with euthanasia where the motive of those who perform it is to respect the wishes of the
patient and to provide the patient with a “good death,” though one important issue is whether a change
in legal policy could restrict the performance of euthanasia to only those cases.
A last introductory point is that I will be examining only secular arguments about euthanasia, though of
course many people’s attitudes to it are inextricable from their religious views. The policy issue is only
whether euthanasia should be permissible, and no one who has religious objections to it should be
required to take any part in it, though of course this would not fully satisfy some opponents.
The Central Ethical Argument for Voluntary Active Euthanasia
The central ethical argument for euthanasia is familiar. It is that the very same two fundamental ethical
values supporting the consensus on patient’s rights to decide about life-sustaining treatment also
support the ethical permissibility of euthanasia. These values are individual self-determination or
autonomy and individual well-being. 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 own values or
conceptions of a good life, and in being left free to act on those decisions. Self-determination is valuable
because it permits people to form and live in accordance with their own conception of a good life, at
least within the bounds of justice and consistent with others doing so as well. In exercising
self-determination people take responsibility for their lives and for the kinds of persons they become. A
central aspect of human dignity lies in people’s capacity to direct their lives in this way. The value of
exercising self-de termination presupposes some minimum of decision making capacities or
competence, which thus limits the scope of euthanasia supported by self-determination; it cannot
justifiably be administered, for example, in cases of serious dementia or treatable clinical depression.
Does the value of individual self-determination extend to the time and manner of one’s death? Most
people are very concerned about the nature of the last stage of their lives. This reflects not just a fear of
experiencing substantial suffering when dying, but also a desire to retain dignity and control during this
last period of life. Death is today increasingly preceded by a long period of significant physical and
mental decline, due in part to the technological interventions of modern medicine. Many people adjust to
these disabilities and find meaning and value in new activities and ways. Others find the impairments
and burdens in the last stage of their lives at some point sufficiently great to make life no longer worth
living. For many patients near death, maintaining the quality of one’s life, avoiding great suffering,
maintaining one’s dignity, and insuring that others remember us as we wish them to become of
paramount importance and outweigh merely extending one’s life. But there is no single, objectively
correct answer for everyone as to when, if at all, one’s life becomes all things considered a burden and
unwanted. If self-determination is a fundamental value, then the great variability among people on this
question makes it especially important that individuals control the manner, circumstances, and timing of
their dying and death.
The other main value that supports euthanasia is individual well-being. It might seem that individual
well-being conflicts with a person’s self-determination when the person requests euthanasia. Life itself is
commonly taken to be a central good for persons, often valued for its own sake, as well as necessary
for pursuit of all other goods within a life. But when a competent patient decides to forgo all further
life-sustaining treatment then the patient, either explicitly or implicitly, commonly decides that the best
life possible for him or her with treatment is of sufficiently poor quality that it is worse than no further life
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at all. Life is no longer considered a benefit by the patient, but has now become a burden. The same
judgment underlies a request for euthanasia: continued life is seen by the patient as no longer a benefit,
but now a burden. Especially in the often severely compromised and debilitated states of many critically
ill or dying patients, there is no objective standard, but only the competent patient’s judgment of whether
continued life is no longer a benefit.
Of course, sometimes there are conditions, such as clinical depression, that call into question whether
the patient has made a competent choice, either to forgo life-sustaining treatment or to seek euthanasia,
and then the patient’s choice need not be evidence that continued life is no longer a benefit for him or
her. Just as with decisions about treatment, a determination of incompetence can warrant not honoring
the patient’s choice; in the case of treatment, we then transfer decisional authority to a surrogate,
though in the case of voluntary active euthanasia a determination that the patient is incompetent means
that choice is not possible.
The value or right of self-determination does not entitle patients to compel physicians to act contrary to
their own moral or professional values. Physicians are moral and professional agents whose own
self-determination or integrity should be respected as well. If performing euthanasia became legally
permissible, but conflicted with a particular physician’s reasonable understanding of his or her moral or
professional responsibilities, the care of a patient who requested euthanasia should be transferred to
another.
Most opponents do not deny that there are some cases in which the values of patient self-determination
and well-being support euthanasia. Instead, they commonly offer two kinds of arguments against it that
on their view outweigh or override this support. The first kind of argument is that in any individual case
where considerations of the patient’s self-determination and well-being do support euthanasia, it is
nevertheless always ethically wrong or impermissible. The second kind of argument grants that in some
individual cases euthanasia may not be ethically wrong, but maintains nonetheless that public and legal
policy should never permit it. The first kind of argument focuses on features of any individual case of
euthanasia, while the second kind focuses on social or legal policy. In the next section I consider the first
kind of argument.
Euthanasia Is the Deliberate Killing of an Innocent Person
The claim that any individual instance of euthanasia is a case of deliberate killing of an innocent person
is, with only minor qualifications, correct. Unlike forgoing life-sustaining treatment, commonly understood
as allowing to die, euthanasia is clearly killing, defined as depriving of life or causing the death of a living
being. While providing morphine for pain relief at doses where the risk of respiratory depression and an
earlier death may be a foreseen but unintended side effect of treating the patient’s pain, in a case of
euthanasia the patient’s death is deliberate or intended even if in both the physician’s ultimate end may
be respecting the patient’s wishes. If the deliberate killing of an innocent person is wrong, euthanasia
would be nearly always impermissible.
In the context of medicine, the ethical prohibition against deliberately killing the innocent derives some of
its plausibility from the belief that nothing in the currently accepted practice of medicine is deliberate
killing. Thus, in commenting on the “It’s Over, Debbie” case, four prominent physicians and bioethicists
could entitle their paper “Doctors Must Not Kill.”( n5) The belief that doctors do not in fact kill requires
the corollary belief that forgoing life-sustaining treatment, whether by not starting or by stopping
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treatment, is allowing to die, not killing. Common though this view is, I shall argue that it is confused and
mistaken.
Why is the common view mistaken? Consider the case of a patient terminally ill with ALS disease. She
is completely respirator dependent with no hope of ever being weaned. She is unquestionably
competent but finds her condition intolerable and persistently requests to be removed from the
respirator and allowed to die. Most people and physicians would agree that the patient’s physician
should respect the patient’s wishes and remove her from the respirator, though this will certainly cause
the patient’s death. The common understanding is that the physician thereby allows the patient to die.
But is that correct?
Suppose the patient has a greedy and hostile son who mistakenly believes that his mother will never
decide to stop her life-sustaining treatment and that even if she did her physician would not remove her
from the respirator. Afraid that his inheritance will be dissipated by a long and expensive hospitalization,
he enters his mother’s room while she is sedated, extubates her, and she dies. Shortly thereafter the
medical staff discovers what he has done and confronts the son. He replies, “I didn’t kill her, I merely
allowed her to die. It was her ALS disease that caused her death.” I think this would rightly be dismissed
as transparent sophistry–the son went into his mother’s room and deliberately killed her. But, of course,
the son performed just the same physical actions, did just the same thing, that the physician would have
done. If that is so, then doesn’t the physician also kill the patient when he extubates her?
I underline immediately that there are important ethical differences between what the physician and the
greedy son do. First, the physician acts with the patient’s consent whereas the son does not. Second,
the physician acts with a good motive–to respect the patient’s wishes and self-determination–whereas
the son acts with a bad motive–to protect his own inheritance. Third, the physician acts in a social role
through which he is legally authorized to carry out the patient’s wishes regarding treatment whereas the
son has no such authorization. These and perhaps other ethically important differences show that what
the physician did was morally justified whereas what the son did was morally wrong. What they do not
show, however, is that the son killed while the physician allowed to die. One can either kill or allow to die
with or without consent, with a good or bad motive, within or outside of a social role that authorizes one
to do so.
The difference between killing and allowing to die that I have been implicitly appealing to here is roughly
that between acts and omissions resulting in death.( n6) Both the physician and the greedy son act in a
manner intended to cause death, do cause death, and so both kill. One reason this conclusion is
resisted is that on a different understanding of the distinction between killing and allowing to die, what
the physician does is allow to die. In this account, the mother’s ALS is a lethal disease whose normal
progression is being held back or blocked by the life-sustaining respirator treatment. Removing this
artificial intervention is then viewed as standing aside and allowing the patient to die of her underlying
disease. I have argued elsewhere that this alternative account is deeply problematic, in part because it
commits us to accepting that what the greedy son does is to allow to die, not kill.( n7) Here, I want to
note two other reasons why the conclusion that stopping life support is killing is resisted.
The first reason is that killing is often understood, especially within medicine, as unjustified causing of
death; in medicine it is thought to be done only accidentally or negligently. It is also increasingly widely
accepted that a physician is ethically justified in stopping life support in a case like that of the ALS
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patient. But if these two beliefs are correct, then what the physician does cannot be killing, and so must
be allowing to die. Killing patients is not, to put it flippantly, understood to be part of physicians’ job
description. What is mistaken in this line of reasoning is the assumption that all killings are unjustified
causings of death. Instead, some killings are ethically justified, including many instances of stopping life
support.
Another reason for resisting the conclusion that stopping life support is often killing is that it is
psychologically uncomfortable. Suppose the physician had stopped the ALS patient’s respirator and had
made the son’s claim, “I didn’t kill her, I merely allowed her to die. It was her ALS disease that caused
her death.” The clue to the psychological role here is how naturally the “merely” modifies “allowed her to
die.” The characterization as allowing to die is meant to shift felt responsibility away from the agent–the
physician–and to the lethal disease process. Other language common in death and dying contexts plays
a similar role; “letting nature take its course ” or “stopping prolonging the dying process” both seem to
shift responsibility from the physician who stops life support to the fatal disease process. However
psychologically helpful these conceptualizations may be in making the difficult responsibility of a
physician’s role m the patient’s death bearable, they nevertheless are confusions. Both physicians and
family members can instead be helped to understand that it is the patient’s decision and consent to
stopping treatment that limits their responsibility for the patient’s death and that shifts that responsibility
to the patient.
Many who accept the difference between killing and allowing to die as the distinction between acts and
omissions resulting in death have gone on to argue that killing is not in itself morally different from
allowing to die.( n8) In this account, very roughly, one kills when one performs an action that causes the
death of a person (we are in a boat, you cannot swim, I push you overboard, and you drown), and one
allows to die when one has the ability and opportunity to prevent the death of another, knows this, and
omits doing so, with the result that the person dies (we are in a boat, you cannot swim, you fall
overboard, I don’t throw you an available life ring, and you drown). Those who see no moral difference
between killing and allowing to die typically employ the strategy of comparing cases that differ in these
and no other potentially morally important respects. This will allow people to consider whether the mere
difference that one is a case of killing and the other of allowing to die matters morally, or whether instead
it is other features that make most cases of killing worse than most instances of allowing to die. Here is
such a pair of cases:
Case 1. A very gravely ill patient is brought to a hospital emergency room and sent up to the ICU. The
patient begins to develop respiratory failure that is likely to require intubation very soon. At that point the
patient’s family members and long-standing physician arrive at the ICU and inform the ICU staff that
there had been extensive discussion about future care with the patient when he was unquestionably
competent Given his grave and terminal illness, as well as his state of debilitation, the patient had firmly
rejected being placed on a respirator under any circumstances, and the family and physician produce
the patient’s advance directive to that effect The ICU staff do not intubate the patient, who dies of
respiratory failure.
Case 2. The same as Case 1 except that the family and physician are slightly delayed in traffic and
arrive shortly after the patient has been intubated and placed on the respirator. The ICU staff extubate
the patient, who dies of respiratory failure.
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In Case 1 the patient is allowed to die, in Case 2 he is killed, but it is hard to see why what is done in
Case 2 is significantly different morally than what is done in Case 1. It must be other factors that make
most killings worse than most allowings to die, and if so, euthanasia cannot be wrong simply because it
is killing instead of allowing to die.
Suppose both my arguments are mistaken. Suppose that killing is worse than allowing to die and that
withdrawing life support is not killing, although euthanasia is. Euthanasia still need not for that reason be
morally wrong. To see this, we need to determine the basic principle for the moral evaluation of killing
persons. What is it that makes paradigm cases of wrongful killing wrongful? One very plausible answer
is that killing denies the victim something that he or she values greatly–continued life or a future.
Moreover, since continued life is necessary for pursuing any of a person’s plans and purposes, killing
brings the frustration of all of these plans and desires as well. In a nutshell, wrongful killing deprives a
person of a valued future, and of all the person wanted and planned to do in that future.
A natural expression of this account of the wrongness of killing is that people have a moral right not to
be killed.( n9) But in this account of the wrongness of killing, the right not to be killed, like other rights,
should be waivable when the person makes a competent decision that continued life is no longer
wanted or a good, but is instead worse than no further life at all. In this view, euthanasia is properly
understood as a case of a person having waived his or her right not to be killed.
This rights view of the wrongness of killing is not, of course, universally shared. Many people’s moral
views about killing have their origins in religious views that human life comes from God and cannot be
justifiably destroyed or taken away, either by the person whose life it is or by another. But in a pluralistic
society like our own with a strong commitment to freedom of religion, public policy should not be
grounded in religious beliefs which many in that society reject I turn now to the general evaluation of
public policy on euthanasia.
Would the Bad Consequences of Euthanasia Outweigh the Good?
The argument against euthanasia at the policy level is stronger than at the level of individual cases,
though even here I believe the case is ultimately unpersuasive, or at best indecisive. The policy level is
the place where the main issues lie, however, and where moral considerations that might override
arguments in favor of euthanasia will be found, if they are found anywhere. It is important to note two
kinds of disagreement about the consequences for public policy of permitting euthanasia. First, there is
empirical or factual disagreement about what the consequences would be. This disagreement is greatly
exacerbated by the lack of firm data on the issue. Second, since on any reasonable assessment there
would be both good and bad consequences, there are moral disagreements about the relative
importance of different effects. In addition to these two sources of disagreement, there is also no single,
well-specified policy proposal for legalizing euthanasia on which policy assessments can focus. But
without such specification, and especially without explicit procedures for protecting against
well-intentioned misuse and ill-intentioned abuse, the consequences for policy are largely speculative.
Despite these difficulties, a preliminary account of the main likely good and bad consequences is
possible. This should help clarify where better data or more moral analysis and argument are needed,
as well as where policy safeguards must be developed.
Potential Good Consequences of Permitting Euthanasia. What are the likely good consequences?
First, if euthanasia were permitted it would be possible to respect the self-determination of competent
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patients who want it, but now cannot get it because of its illegality. We simply do not know how many
such patients and people there are. In the Netherlands, with a population of about 14.5 million (in 1987),
estimates in a recent study were that about 1,900 cases of voluntary active euthanasia or physicianassisted
suicide occur annually. No straightforward extrapolation to the United States is possible for
many reasons, among them, that we do not know how many people here who want euthanasia now get
it, despite its illegality. Even with better data on the number of persons who want euthanasia but cannot
get it, significant moral disagreement would remain about how much weight should be given to any
instance of failure to respect a person’s self-determination in this way.
One important factor substantially affecting the number of persons who would seek euthanasia is the
extent to which an alternative is available. The widespread acceptance in the law, social policy, and
medical practice of the right of a competent patient to forgo life-sustaining treatment suggests that the
number of competent persons in the United States who would want euthanasia if it were permitted is
probably relatively small.
A second good consequence of making euthanasia legally permissible benefits a much larger group.
Polls have shown that a majority of the American public believes that people should have a right to
obtain euthanasia if they want it( n10) No doubt the vast majority of those who support this right to
euthanasia will never in fact come to want euthanasia for themselves. Nevertheless, making it legally
permissible would reassure many people that if they ever do want euthanasia they would be able to
obtain it. This reassurance would supplement the broader control over the process of dying given by the
right to decide about life-sustaining treatment. Having fire insurance on one’s house benefits all who
have it, not just those whose houses actually burn down, by reassuring them that in the unlikely event of
their house burning down, they will receive the money needed to rebuild it. Likewise, the legalization of
euthanasia can be thought of as a kind of insurance policy against being forced to endure a protracted
dying process that one has come to find burdensome and unwanted, especially when there is no
life-sustaining treatment to forgo. The strong concern about losing control of their care expressed by
many people who face serious illness likely to end in death suggests that they give substantial
importance to the legalization of euthanasia as a means of maintaining this control.
A third good consequence of the legalization of euthanasia concerns patients whose dying is filled with
severe and unrelievable pain or suffering. When there is a life-sustaining treatment that, ifforgone, will
lead relatively quickly to death, then doing so can bring an end to these patients’ suffering without
recourse to euthanasia. For patients receiving no such treatment, however, euthanasia may be the only
release from their otherwise prolonged suffering and agony. This argument from mercy has always been
the strongest argument for euthanasia in those cases to which it applies.( n11)
The importance of relieving pain and suffering is less controversial than is the frequency with which
patients are forced to undergo untreatable agony that only euthanasia could relieve. If we focus first on
suffering caused by physical pain, it is crucial to distinguish pain that could be adequately relieved with
modern methods of pain control, though it in fact is not, from pain that is relievable only by death.( n12)
For a variety of reasons, including some physicians’ fear of hastening the patient’s death, as well as the
lack of a publicly accessible means for assessing the amount of the patient’s pain, many patients suffer
pain that could be, but is not, relieved.
Specialists in pain control, as for example the pain of terminally ill cancer patients, argue that there are
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very few patients whose pain could not be adequately controlled, though sometimes at the cost of so
sedating them that they are effectively unable to interact with other people or their environment Thus,
the argument from mercy in cases of physical pain can probably be met in a large majority of cases by
providing adequate measures of pain relief. This should be a high priority, whatever our legal policy on
euthanasia–the relief of pain and suffering has long been, quite properly, one of the central goals of
medicine. Those cases in which pain could be effectively relieved, but in fact is not, should only count
significantly in favor of legalizing euthanasia if all reasonable efforts to change pain management
techniques have been tried and have failed.
Dying patients often undergo substantial psychological suffering that is not fully or even principally the
result of physical pain.( n13) The knowledge about how to relieve this suffering is much more limited
than in the case of relieving pain, and efforts to do so are probably more often unsuccessful. If the
argument from mercy is extended to patients experiencing great and unrelievable psychological
suffering, the numbers of patients to which it applies are much greater.
One last good consequence of legalizing euthanasia is that once death has been accepted, it is often
more humane to end life quickly and peacefully, when that is what the patient wants. Such a death will
often be seen as better than a more prolonged one. People who suffer a sudden and unexpected death,
for example by dying quickly or in their sleep from a heart attack or stroke, are often considered lucky to
have died in this way. We care about how we die in part because we care about how others remember
us, and we hope they will remember us as we were in “good times” with them and not as we might be
when disease has robbed us of our dignity as human beings. As with much in the treatment and care of
the dying, people’s concerns differ in this respect, but for at least some people, euthanasia will be a
more humane death than what they have often experienced with other loved ones and might otherwise
expect for themselves.
Some opponents of euthanasia challenge how much importance should be given to any of these good
consequences of permitting it, or even whether some would be good consequences at all. But more
frequently, opponents cite a number of bad consequences that permitting euthanasia would or could
produce, and it is to their assessment that I now turn.
Potential Bad Consequences of Permitting Euthanasia. Some of the arguments against permitting
euthanasia are aimed specifically against physicians, while others are aimed against anyone being
permitted to perform it. I shall first consider one argument of the former sort. Permitting physicians to
perform euthanasia, it is said, would be incompatible with their fundamental moral and professional
commitment as healers to care for patients and to protect life. Moreover, if euthanasia by physicians
became common, patients would come to fear that a medication was intended not to treat or care, but
instead to kill, and would thus lose trust in their physicians. This position was forcefully stated in a paper
by Willard Gaylin and his colleagues:
The very soul of medicine is on trial. .. This issue touches medicine at its moral center; if this moral
center collapses, if physicians become killers or are even licensed to kill, the profession–and, therewith,
each physician–will never again be worthy of trust and respect as healer and comforter and protector of
life in all its frailty.
These authors go on to make clear that, while they oppose permitting anyone to perform euthanasia,
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their special concern is with physicians doing so:
We call on fellow physicians to say that they will not deliberately kill. We must also say to each of our
fellow physicians that we will not tolerate killing of patients and that we shall take disciplinary action
against doctors who kill. And we must say to the broader community that if it insists on tolerating or
legalizing active euthanasia, it will have to find nonphysicians to do its killing.( n14)
If permitting physicians to kill would undermine the very “moral center” of medicine, then almost certainly
physicians should not be permitted to perform euthanasia. But how persuasive is this claim? Patients
should not fear, as a consequence of permitting voluntary’ active euthanasia, that their physicians will
substitute a lethal injection for what patients want and believe is part of their care. If active euthanasia is
restricted to cases in which it is truly voluntary, then no patient should fear getting it unless she or he
has voluntarily requested it. (The fear that we might in time also come to accept nonvoluntary, or even
involuntary, active euthanasia is a slippery slope worry I address below.) Patients’ trust of their
physicians could be increased, not eroded, by knowledge that physicians will provide aid in dying when
patients seek it.
Might Gaylin and his colleagues nevertheless be correct in their claim that the moral center of medicine
would collapse if physicians were to become killers? This question raises what at the deepest level
should be the guiding aims of medicine, a question that obviously cannot be fully explored here. But I do
want to say enough to indicate the direction that I believe an appropriate response to this challenge
should take. In spelling out above what I called the positive argument for voluntary active euthanasia, I
suggested that two principal values–respecting patients’ self-determination and promoting their
well-being–underlie the consensus that competent patients, or the surrogates of incompetent patients,
are entitled to refuse any life-sustaining treatment and to choose from among available alternative
treatments. It is the commitment to these two values in guiding physicians’ actions as healers,
comforters, and protectors of their patients’ lives that should be at the “moral center” of medicine, and
these two values support physicians’ administering euthanasia when their patients make competent
requests for it.
What should not be at that moral center is a commitment to preserving patients’ lives as such, without
regard to whether those patients want their lives preserved or judge their preservation a benefit to them.
Vitalism has been rejected by most physicians, and despite some statements that suggest it, is almost
certainly not what Gaylin and colleagues intended. One of them, Leon Kass, has elaborated elsewhere
the view that medicine is a moral profession whose proper aim is “the naturally given end of health,”
understood as the wholeness and well-working of the human being; “for the physician, at least, human
life in living bodies commands respect and reverence–by its very nature.” Kass continues, “the deepest
ethical principle restraining the physician’s power is not the autonomy or freedom of the patient; neither
is it his own compassion or good intention. Rather, it is the dignity and mysterious power of human life
itself.”( n15) I believe Kass is in the end mistaken about the proper account of the aims of medicine and
the limits on physicians’ power, but this difficult issue will certainly be one of the central themes in the
continuing debate about euthanasia.
A second bad consequence that some foresee is that permitting euthanasia would weaken society’s
commitment to provide optimal care for dying patients. We live at a time in which the control of health
care costs has become, and is likely to continue to be, the dominant focus of health care policy. If
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euthanasia is seen as a cheaper alternative to adequate care and treatment, then we might become
less scrupulous about providing sometimes costly support and other services to dying patients.
Particularly if our society comes to embrace deeper and more explicit rationing of health care, frail,
elderly, and dying patients will need to be strong and effective advocates for their own health care and
other needs, although they are hardly in a position to do this. We should do nothing to weaken their
ability to obtain adequate care and services.
This second worry is difficult to assess because there is little firm evidence about the likelihood of the
feared erosion in the care of dying patients. There are at least two reasons, however, for skepticism
about this argument. The first is that the same worry could have been directed at recognizing patients’
or surrogates’ rights to forgo life-sustaining treatment, yet there is no persuasive evidence that
recognizing the right to refuse treatment has caused a serious erosion in the quality of care of dying
patients. The second reason for skepticism about this worry is that only a very small proportion of
deaths would occur from euthanasia if it were permitted. In the Netherlands, where euthanasia under
specified circumstances is permitted by the courts, though not authorized by statute, the best estimate
of the proportion of overall deaths that result from it is about 2 percent.( n16) Thus, the vast majority of
critically ill and dying patients will not request it, and so will still have to be cared for by physicians,
families, and others. Permitting euthanasia should not diminish people’s commitment and concern to
maintain and improve the care of these patients.
A third possible bad consequence of permitting euthanasia (or even a public discourse in which strong
support for euthanasia is evident) is to threaten the progress made in securing the rights of patients or
their surrogates to decide about and to refuse life-sustaining treatment.( n17) This progress has been
made against the backdrop of a clear and firm legal prohibition of euthanasia, which has provided a
relatively bright line limiting the dominion of others over patients’ lives. It has therefore been an
important reassurance to concerns about how the authority to take steps ending life might be misused,
abused, or wrongly extended.
Many supporters of the right of patients or their surrogates to refuse treatment strongly oppose
euthanasia, and if forced to choose might well withdraw their support of the right to refuse treatment
rather than accept euthanasia. Public policy in the last fifteen years has generally let life-sustaining
treatment decisions be made in health care settings between physicians and patients or their
surrogates, and without the involvement of the courts. However, if euthanasia is made legally
permissible greater involvement of the courts is likely, which could in turn extend to a greater court
involvement in life-sustaining treatment decisions. Most agree, however, that increased involvement of
the courts in these decisions would be undesirable, as it would make sound decisionmaking more
cumbersome and difficult without sufficient compensating benefits.
As with the second potential bad consequence of permitting euthanasia, this third consideration too is
speculative and difficult to assess. The feared erosion of patients’ or surrogates’ rights to decide about
life-sustaining treatment, together with greater court involvement in those decisions, are both possible.
However, I believe there is reason to discount this general worry. The legal rights of competent patients
and, to a lesser degree, surrogates of incompetent patients to decide about treatment are very firmly
embedded in a long line of informed consent and life-sustaining treatment cases, and are not likely to be
eroded by a debate over, or even acceptance of, euthanasia. It will not be accepted without safeguards
that reassure the public about abuse, and if that debate shows the need for similar safeguards for some
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life-sustaining treatment decisions they should be adopted there as well. In neither case are the only
possible safeguards greater court involvement, as the recent growth of institutional ethics committees
shows.
The fourth potential bad consequence of permitting euthanasia has been developed by David Velleman
and turns on the subtle point that making a new option or choice available to people can sometimes
make them worse off, even if once they have the choice they go on to choose what is best for them.(
n18) Ordinarily, people’s continued existence is viewed by them as given, a fixed condition with which
they must cope. Making euthanasia available to people as an option denies them the alternative of
staying alive by default. If people are offered the option of euthanasia, their continued existence is now a
choice for which they can be held responsible and which they can be asked by others to justify. We
care, and are right to care, about being able to justify ourselves to others. To the extent that our society
is unsympathetic to justifying a severely dependent or impaired existence, a heavy psychological burden
of proof may be placed on patients who think their terminal illness or chronic infirmity is not a sufficient
reason for dying. Even if they otherwise view their life as worth living, the opinion of others around them
that it is not can threaten their reason for living and make euthanasia a rational choice. Thus the
existence of the option becomes a subtle pressure to request it.
This argument correctly identifies the reason why offering some patients the option of euthanasia would
not benefit them. Velleman takes it not as a reason for opposing all euthanasia, but for restricting it to
circumstances where there are “unmistakable and overpowering reasons for persons to want the option
of euthanasia, ” and for denying the option in all other cases. But there are at least three reasons why
such restriction may not be warranted. First, polls and other evidence support that most Americans
believe euthanasia should be permitted (though the recent defeat of the referendum to permit it in the
state of Washington raises some doubt about this support). Thus, many more people seem to want the
choice than would be made worse off by getting it. Second, if giving people the option of ending their life
really makes them worse off, then we should not only prohibit euthanasia, but also take back from
people the right they now have to decide about-life-sustaining treatment. The feared harmful effect
should already have occurred from securing people’s right to refuse life-sustaining treatment, yet there
is no evidence of any such widespread harm or any broad public desire to rescind that right. Third, since
there is a wide range of conditions in which reasonable people can and do disagree about whether they
would want continued life, it is not possible to restrict the permissibility of euthanasia as narrowly as
Velleman suggests without thereby denying it to most persons who would want it; to permit it only in
cases in which virtually everyone would want it would be to deny it to most who would want it.
A fifth potential bad consequence of making euthanasia legally permissible is that it might weaken the
general legal prohibition of homicide. This prohibition is so fundamental to civilized society, it is argued,
that we should do nothing that erodes it. If most cases of stopping life support are killing, as I have
already argued, then the court cases permitting such killing have already in effect weakened this
prohibition. However, neither the courts nor most people have seen these cases as killing and so as
challenging the prohibition of homicide. The courts have usually grounded patients’ or their surrogates’
rights to refuse life-sustaining treatment in rights to privacy, liberty, self-determination, or bodily integrity,
not in exceptions to homicide laws.
Legal permission for physicians or others to perform euthanasia could not be grounded in patients’
rights to decide about medical treatment. Permitting euthanasia would require qualifying, at least in
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effect, the legal prohibition against homicide, a prohibition that in general does not allow the consent of
the victim to justify or excuse the act. Nevertheless, the very same fundamental basis of the right to
decide about life-sustaining treatment–respecting a person’s self-determination-does support
euthanasia as well. Individual self-determination has long been a well-entrenched and fundamental
value in the law, and so extending it to euthanasia would not require appeal to novel legal values or
principles. That suicide or attempted suicide is no longer a criminal offense in virtually all states
indicates an acceptance of individual self-determination in the taking of one’s own life analogous to that
required for voluntary active euthanasia The legal prohibition (in most states) of assisting in suicide and
the refusal in the law to accept the consent of the victim as a possible justification of homicide are both
arguably a result of difficulties in the legal process of establishing the consent of the victim after the fact.
If procedures can be designed that clearly establish the voluntariness of the person’s request for
euthanasia it would under those procedures represent a carefully circumscribed qualification on the
legal prohibition of homicide. Nevertheless, some remaining worries about this weakening can be
captured in the final potential bad consequence, to which I will now turn.
This final potential bad consequence is the central concern of many opponents of euthanasia and, I
believe, is the most serious objection to a legal policy permitting it. According to this “slippery slope”
worry, although active euthanasia may be morally permissible in cases in which it is unequivocally
voluntary and the patient finds his or her condition unbearable, a legal policy permitting euthanasia
would inevitably lead to active euthanasia being performed in many other cases in which it would be
morally wrong. To prevent those other wrongful cases of euthanasia we should not permit even morally
justified performance of it.
Slippery slope arguments of this form are problematic and difficult to evaluate.( n19) From one
perspective, they are the last refuge of conservative defenders of the status quo. When all the
opponent’s objections to the wrongness of euthanasia itself have been met, the opponent then shifts
ground and acknowledges both that it is not in itself wrong and that a legal policy which resulted only in
its being performed would not be bad. Nevertheless, the opponent maintains, it should still not be
permitted because doing so would result in its being performed in other cases in which it is not voluntary
and would be wrong. In this argument’s most extreme form, permitting euthanasia is the first and fateful
step down the slippery slope to Nazism. Once on the slope we will be unable to get off.
Now it cannot be denied that it is possible that permitting euthanasia could have these fateful
consequences, but that cannot be enough to warrant prohibiting it if it is otherwise justified. A similar
possible slippery slope worry could have been raised to securing competent patients’ rights to decide
about life support, but recent history shows such a worry would have been unfounded. It must be
relevant how likely it is that we will end with horrendous consequences and an unjustified practice of
euthanasia. How like, and widespread would the abuses and unwarranted extensions of permitting it
be? By abuses, I mean the performance of euthanasia that fails to satisfy the conditions required for
voluntary active euthanasia, for example, if the patient has been subtly pressured to accept it. By
unwarranted extensions of policy, I mean later changes in legal policy to permit not just voluntary
euthanasia, but also euthanasia in cases in which, for example, it need not be fully voluntary. Opponents
of voluntary euthanasia on slippery slope grounds have not provided the data or evidence necessary to
turn their speculative concerns into well-grounded likelihoods.
It is at least clear, however, that both the character and likelihood of abuses of a legal policy permitting
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euthanasia depend in significant part on the procedures put in place to protect against them. I will not try
to detail fully what such procedures might be, but will just give some examples of what they might
include:
The patient should be provided with all relevant information about his or her medical condition,
current prognosis, available alternative treatments, and the prognosis of each.
1.
Procedures should ensure that the patient’s request for euthanasia is stable or enduring (a brief
waiting period could be required) and fully voluntary (an advocate for the patient might be appointed
to ensure this).
2.
All reasonable alternatives must have been explored for improving the patient’s quality of life and
relieving any pain or suffering.
3.
A psychiatric evaluation should ensure that the patient’s request is not the result of a treatable
psychological impairment such as depression.( n20)
4.
These examples of procedural safeguards are all designed to ensure that the patient’s choice is fully
informed, voluntary, and competent, and so a true exercise of self-determination. Other proposals for
euthanasia would restrict its permissibility further–for example, to the terminally ill–a restriction that
cannot be supported by self-determination. Such additional restrictions might, however, be justified by
concern for limiting potential harms from abuse. At the same time, it is important not to impose
procedural or substantive safeguards so restrictive as to make euthanasia impermissible or practically
infeasible in a wide range of Justified cases.
These examples of procedural safeguards make clear that it is possible to substantially reduce, though
not to eliminate, the potential for abuse of a policy permitting voluntary active euthanasia. Any
legalization of the practice should be accompanied by a well-considered set of procedural safeguards
together with an ongoing evaluation of its use. Introducing euthanasia into only a few states could be a
form of carefully limited and controlled social experiment that would give us evidence about the benefits
and harms of the practice. Even then firm and uncontroversial data may remain elusive, as the
continuing controversy over what has taken place in the Netherlands in recent years indicates.( n21)
The Slip into Nonvoluntary Active Euthanasia. While I believe slippery slope worries can largely be
limited by making necessary distinctions both in principle and in practice, one slippery slope concern is
legitimate. There is reason to expect that legalization of voluntary active euthanasia might soon be
followed by strong pressure to legalize some nonvoluntary euthanasia of incompetent patients unable to
express their own wishes. Respecting a person’s self-determination and recognizing that continued life
is not always of value to a person can support not only voluntary active euthanasia, but some
nonvoluntary euthanasia as well. These are the same values that ground competent patients’ right to
refuse life-sustaining treatment. Recent history here is instructive. In the medical ethics literature, in the
courts since Quinlan, and in norms of medical practice, that right has been extended to incompetent
patients and exercised by a surrogate who is to decide as the patient would have decided in the
circumstances if competent.( n22) It has been held 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.
Life-sustaining treatment for incompetent patients is today frequently forgone on the basis of a
surrogate’s decision, or less frequently on the basis of an advance directive executed by the patient
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while still competent. The very same logic that has extended the right to refuse life-sustaining treatment
from a competent patient to the surrogate of an incompetent patient (acting with or without a formal
advance directive from the patient) may well extend the scope of active euthanasia. The argument will
be, Why continue to force unwanted life on patients just because they have now lost the capacity to
request euthanasia from us?
A related phenomenon may reinforce this slippery slope concern. In the Netherlands, what the courts
have sanctioned has been clearly restricted to voluntary euthanasia. In itself, this serves as some
evidence that permitting it need not lead to permitting the nonvoluntary variety. There is some indication,
however, that for many Dutch physicians euthanasia is no longer viewed as a special action, set apart
from their usual practice and restricted only to competent persons.( n23) Instead, it is seen as one end
of a spectrum of caring for dying patients. When viewed in this way it will be difficult to deny euthanasia
to a patient for whom it is seen as the best or most appropriate form of care simply because that patient
is now incompetent and cannot request it.
Even if voluntary active euthanasia should slip into nonvoluntary active euthanasia, with surrogates
acting for incompetent patients, the ethical evaluation is more complex than many opponents of
euthanasia allow. Just as in the case of surrogates’ decisions to forgo life-sustaining treatment for
incompetent patients, so also surrogates’ decisions to request euthanasia for incompetent persons
would often accurately reflect what the incompetent person would have wanted and would deny the
person nothing that he or she would have considered worth having. Making nonvoluntary active
euthanasia legally permissible, however, would greatly enlarge the number of patients on whom it might
be performed and substantially enlarge the potential for misuse and abuse. As noted above, frail and
debilitated elderly people, often demented or otherwise incompetent and thereby unable to defend and
assert their own interests, may be especially vulnerable to unwanted euthanasia.
For some people, this risk is more than sufficient reason to oppose the legalization of voluntary
euthanasia. But while we should in general be cautious about inferring much from the experience in the
Netherlands to what our own experience in the United States might be, there may be one important
lesson that we can learn from them. One commentator has noted that in the Netherlands families of
incompetent patients have less authority than do families in the United States to act as surrogates for
incompetent patients in making decisions to forgo life-sustaining treatment.( n24) From the Dutch
perspective, it may be we in the United States who are already on the slippery slope in having given
surrogates broad authority to forgo life sustaining treatment for incompetent persons. In this view, the
more important moral divide, and the more important with regard to potential for abuse, is not between
forgoing life-sustaining treatment and euthanasia, but instead between voluntary and nonvoluntary
performance of either. If this is correct, then the more important issue is ensuring the appropriate
principles and procedural safeguards for the exercise of decisionmaking authority by surrogates for
incompetent persons in all decisions at the end of life. This may be the correct response to slippery
slope worries about euthanasia.
I have cited both good and bad consequences that have been thought likely from a policy change
permitting voluntary active euthanasia, and have tried to evaluate their likelihood and relative
importance. Nevertheless, as I noted earlier, reasonable disagreement remains both about the
consequences of permitting euthanasia and about which of these consequences are more important.
The depth and strength of public and professional debate about whether, all things considered,
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permitting euthanasia would be desirable or undesirable reflects these disagreements. While my own
view is that the balance of considerations supports permitting the practice, my principal purpose here
has been to clarify the main issues.
The Role of Physicians
If euthanasia is made legally permissible, should physicians take part in it? Should only physicians be
permitted to perform it, as is the case in the Netherlands? In discussing whether euthanasia is
incompatible with medicine’s commitment to curing, caring for, and comforting patients, I argued that it is
not at odds with a proper understanding of the aims of medicine, and so need not undermine patients’
trust in their physicians. If that argument is correct, then physicians probably should not be prohibited,
either by law or by professional norms, from taking part in a legally permissible practice of euthanasia
(nor, of course, should they be compelled to do so if their personal or professional scruples forbid it).
Most physicians in the Netherlands appear not to understand euthanasia to be incompatible with their
professional commitments.
Sometimes patients who would be able to end their lives on their own nevertheless seek the assistance
of physicians. Physician involvement in such cases may have important benefits to patients and others
beyond simply assuring the use of effective means. Historically, in the United States suicide has carried
a strong negative stigma that many today believe unwarranted. Seeking a physician’s assistance, or
what can almost seem a physician’s blessing, may be away of trying to remove that stigma and show
others that the decision for suicide was made with due seriousness and was justified under the
circumstances. The physician’s involvement provides a kind of social approval, or more accurately helps
counter what would otherwise be unwarranted social disapproval.
There are also at least two reasons for restricting the practice of euthanasia to physicians only. First,
physicians would inevitably be involved in some of the important procedural safeguards necessary to a
defensible practice, such as seeing to it that the patient is well-informed about his or her condition,
prognosis, and possible treatments, and ensuring that all reasonable means have been taken to
improve the quality of the patient’s life. Second, and probably more important, one necessary protection
against abuse of the practice is to limit the persons given authority to perform it, so that they can be held
accountable for their exercise of that authority. Physicians, whose training and professional norms give
some assurance that they would perform euthanasia responsibly, are an appropriate group of persons to
whom the practice may be restricted.
Acknowledgments
Earlier versions of this paper were presented at the American Philosophical Association Central Division
meetings (at which David Velleman provided extremely helpful comments), Massachusetts General
Hospital, Yale University School of Medicine, Princeton University, Brown University, and as the Brin
Lecture at The Johns Hopkins School of Medicine. I am grateful to the audiences on each of these
occasions, to several anonymous reviewers, and to Norman Daniels for helpful comments. The paper
was completed while I was a Fellow in the Program in Ethics and the Professions at Harvard University.
`I Gave Him All the Morphine. . .in My Bag. It Wasn’t Easy.’
“I’ve never shared this with anyone,” says the retired internist who looks like the subject of an Andrew
Wyeth painting. “Not with the patient’s family, not with anyone else. I’ve never even told my wife about
this one. This was probably the toughest one.”
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The patient was a retired business executive and attorney in his early 70s, whose attention to physical
fitness could only be described as a fetish and for whom control was the dominant element in his life. He
was used to doing things his way, including leaving home and business for up to two months a year to
travel the globe in search of high adventure.
“He developed colon cancer and had some problems with intestinal obstruction and was clearly headed
for a kind of miserable end, not just pain, but obstruction and vomiting, a demeaning thing that he just
could not think of facing.”
Not unexpectedly, having so controlled his life, the patient wanted to control his death. The physician
agreed and gave him a hypodermic of morphine to keep in a jar in his bedroom.
But as often happens in such cases, as the cancer spread the patient was given ever increasing doses
of morphine with a home IV pump, and he developed a tolerance for the drug. Clearly, the physician
thought, the single syringe was not going to do the job.
“I didn’t want to go through the scenario I did with another patient, where he’d taken something and not
have it work. I knew that the morphine would never do it–on the other hand I never carry anything in my
bag that’s adequate to resolve the problem. But I had thought that probably two full, 20cc, ampules of
morphine would be sufficient. So I went up and talked with him,” says the physician, and the patient told
him he wanted out.
“He said, `I don’t want to get you in any legal trouble,’ and I said,
`No, that’s my problem’ –he didn’t want me to jeopardize myself. I didn’t make him sign anything, or
make him say… [what he wanted] in so many words, but we had a clear understanding that this was it.
The family waited in the dining room, the son and the mother. They didn’t know what I was doing and
they never asked.
“I gave him all the morphine and all the atropine I had in my bag. It wasn’t easy. It’s the only time I’ve
ever done this, but I felt in his case that it was extraordinary. He never felt anything and it worked all
right. I think his wife knows and is very grateful, but I’ve never discussed it.”
The physician is convinced he did the right thing in killing his patient of many years, yet the act does not
sit easily. It’s just the uncomfortable feeling that you are the actual mechanism. It’s a step that we
normally take when we say, `I’m not going to give antibiotics for this bout of pneumonia in this person
who’s comatose.’
“It’s the only time I’ve ever done anything that direct. It’s not part of your training, it’s not part of the
Hippocratic oath, it’s not part of anything that’s justified. And yet, I felt that there was no other solution to
the situation, and when you take on medicine YOU put yourself through uncomfortable situations,
hopefully for the benefit of your patients.”
From “Death on Request” by B. D.
Colen. A Newsday article reprinted by
permission Newsday, Inc. @ 1991.
‘She Wanted Out Now’
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An internist, who three times in twenty-seven years has provided terminally ill patients with the means to
kill themselves, recalls when he provided aid-in-dying to a patient he barely knew.
A woman in her fifties, who was dying of breast cancer that had metastasized throughout her body,
“somehow or other knew that I was interested in this subject of the dying patient, so she called me up on
the phone one day,” the physician recalls. “She lived in a neighboring town, five or six miles away, and
asked if she could come see me about a very important matter concerning her final illness.”
When the woman arrived in the physician’s office it turned out that what “she wanted was to have me
assist her in dying with a prescription for pills, because her physician would not. She’d been a patient of
some physicians at a cancer center and had had beautiful care. They’d done quite well by her. But at
this point she had absolutely run out of options and there was nothing more that could be done. And she
was miserable. She had a tightly distended abdomen, was highly uncomfortable and in moderately
severe pain and just was generally miserable. And she wanted out. She wanted out now.
“After listening to her and talking with her and her husband, I said I was unwilling to do anything for her
unless she was my patient,” the physician recalls, stressing both that he had to convince himself of the
woman’s medical need, and protect himself against possible legal repercussions.
The woman and the internist each spoke by phone with the woman’s specialist, explaining that she
wanted to be cared for by the internist, and her records were transferred to him. The following day, the
internist says, ‘I had her come back and did a complete physical and history and wrote it all down so it
was thoroughly documented that this was a patient of mine.
“Then I gave her husband a prescription for sleeping pills in his name and I gave her one. Her husband
took them to two different drug stores and within a day or two she took the pills. He called me up early
one morning and said she had died overnight. He was aware when she took the pills and helped her
with this. Then he went to another part of the house and returned a few hours later and she had died
That was good.
“This was all relatively compressed in time; from the time I first met her until she took the pills and died
was a matter of a week,” he acknowledges. ‘In this instance I felt perfectly okay about it because I was
so convinced her disease was so far progressed. And her husband was highly supportive, and after this
he continued to be my patient and on a number of occasions expressed his gratitude for what I had
done.
“I think you draw the line at your own sense of comfort about it,” the internist says. “Each of the
instances that I’ve had anything to do with, either withdrawing treatment or assisting in suicide, they’ve
all been instances that I have felt perfectly okay about. The situation has been so bad, clearly so bad,
that I didn’t have a problem with it in my own mind. Now this sets me up as the judge, and I don’t claim
to be all knowing. But in the instances where it was really needed, it seemed to me to be so clear cut,
and there was no alternative.
“It’s not a matter of killing patients. There’s a difference between euthanasia and assisted suicide. The
physician is involved m helping facilitate, yes, but the patient does the final act, and there is a difference
there.”
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From “Death on Request” B.
D. A Newsday article
reprinted by
permission. Newsday, Inc.
Copyright 1991.
Death Wish Honored, Despite Doubts
That an action is legal does not necessarily make it any less gut-wrenching, as a physician learned
when he participated in what might be termed court-sanctioned euthanasia.
As he vividly recalls the incident, a woman in her forties awoke from a neurosurgical attempt to remove
a slow-growing, malignant brain tumor, only to find herself a respirator-dependent quadriplegic. A vital,
independent woman used to controlling all aspects of her life, she attempted in her last year to adjust.
“When I saw her I think she’d been on a respirator for about two-and-a-halfyears, ” says the physician.
“She’d gone through a lot of physical therapy and was seen by a lot of doctors, and after a year began
asking much more vigorously for the respirator to be turned off. But she couldn’t find anybody who
would do it–which kind of surprises me because this was only a couple of years ago.”
The woman decided to take her case to court, and the physician, an expert on the care of the dying,
was asked to evaluate her. “She was being cared for by a couple of nurses in a hospice program, and
they thought I would just come in that day and turn off the respirator. But I did a fairly prolonged
evaluation on her that took weeks, and had her seen by other people.” Despite that, and despite
speaking to the physicians who had cared for her over the two years, the physician says he couldn’t
understand the woman’s reasons for wanting to end her life.
“I’m not sure I ever had a good feeling for why she felt this way, but she just felt life was not worth living
if you couldn’t be independent, that it was not enough to talk and eat and move around and get out in
her van. She lived mostly in a wheelchair, was really independent at home. But there was just a strong
sense that life was not worth living.”
The judge who heard the woman’s case agreed that she had a right to refuse life-sustaining treatment,
and he issued an order protecting any medical personnel who turned off the machine.
The physician agreed to help the woman, but had problems. ‘In the first place, I didn’t know how to turn
off a respirator and have her comfortable, and I didn’t know how to find out about it either–that’s not
something one learns how to do in medical school. I had to make some phone calls that I felt very
uncomfortable about, to people who I thought would know about it, but it wasn’t like I could just read
about it or pick up a book. One of the problems is even if you’re going to do it, how do you do it without
harming people?”
He continues: “There were lots of discussions about how to do it, who was going to be in the room, and
so on and so forth, and the family decided they wanted to be outside the room–she was in her bedroom
and they wanted to be in the living room, although as it turns out, they all came in. And the two nurses
who had been caring for her for many months wanted to be there, so in essence it was done with the
whole family there.
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“She was lying in her bed. She said her final goodbyes to everybody, kissing them and crying. It wasn’t
enormously demonstrative at this point, but it had been going on for years and she had been saying
goodbye for weeks. I remember one of the nurses was just fed up and wanted to get it over with.”
“I’d sort of bitten the bullet at that point,” says the physician, to whom dying and death were old
companions, “but I was scared I was worried that something might go wrong with the medicine, I worried
that I’d botch it. I’d gotten some advice, and I’d had backups, but… I put in an intravenous line and gave
her opioids and barbiturates to put her to sleep. She was deeply asleep and unresponsive to pain and
we turned off the respirator,” he says, pausing and sighing deeply.
“She continued to breathe for another ten, fifteen, minutes and we kind of watched her slowly stop
breathing. It was a very painful experience. My head knew … felt… that this was what she wanted and it
was the right thing, and everybody had agreed to it. But it was sort of awful to watch somebody who I
basically felt was viable and able to lead a meaningful life from my viewpoint, to see her die. It was
pretty ugly and pretty much made me decide not to do that again. I had distasteful feelings and a gut
reaction that this was not something I wanted to do.”
The physician says that ethical terms and distinctions are useful, but he recognizes that the woman’s
case blurred them. “You could say that we just withdrew treatment and gave her something to make her
comfortable, or you could say that we took her life. But I don’t think it matters. What matters to me is this
is what she wanted.
“She’d been given everything to lead a happier life. She was not depressed; that was the conclusion
reached by three sets of competent psychiatrists. She’d even been medicated with the presumption that
she might be depressed and that might help her. She wasn’t physically suffering. There was no financial
incentive. Her family seemed happy to have her around. This was her choice ultimately, and something
that had been her wish for a year, or two years or three years was not going to change, as far as I could
see. I guess the other side is she felt like it was a living hell.”
However, he adds, while he believes he did the right thing, “it really goes against the grain to kill
somebody, to do something of this sort. There’s a real potential to tarnish one’s image, something that’s
important… if patients think you can turn against them and kill them.”
From “Death on Request” by B. D.
Colen. A Newsday article reprinted
by permission.
Newsday, Inc. Copyright 1991.
References
(n1.) President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and
Behavioral Research, Deciding to Forego Life-Sustaining Treatment (Washington, D.C.: U.S.
Government Printing Office,1983); The Hastings Center, Guidelines on the Termination of Life
Sustaining Treatment and Care of the Dying (Bloomington: Indiana University Press, 1987); Current
Opinions of the Council on Ethical and Judicial Affairs of the American Medical Association–1989:
Withholding or Withdrawing Life-Prolonging Treatment (Chicago: American Medical Association, 1989);
George Annas and Leonard Glantz, “The Right of Elderly Patients to Refuse Life-Sustaining Treatment,”
Millbank Memorial Quarterly 64, suppl. 2 (1986): 95-162; Robert E Weir, Abating Treatment with
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Critically Ill Patients (New York: Oxford University Press, 1989); Sidney J. Wanzer et al. “The Physician’s
Responsibility toward Hopelessly Ill Patients,” NEJM 310 (1984): 955-59.
(n2.) M.A.M. de Wachter, “Active Euthanasia in the Netherlands,”JAMA 262, no. 23 (1989): 3315-19.
(n3.) Anonymous, “It’s Over, Debbie,” JAMA 259 (1988): 272; Tlmothy E. Quill, “Death and Dignity,”
NEJM 322 (1990): 1881-83.
(n4.) Wanzer et al., “The Physician’s Responsibility toward Hopelessly Ill Patients: A Second Look,”
NEJM 320 (1989): 844-49
(n5.) Willard Gaylin, Leon R. Kass, Edmund D. Pellegrino, and Mark Siegler, “Doctors Must Not Kill,”
JAMA 259 (1988): 2139-40.
(n6.) Bonnie Steinbock, ea., Killing and Allowing to Die (Englewood Cliffs, NJ.: Prentice Hall, 1980).
(n7.) Dan W. Brock, “Forgoing Food and Water: Is It Killing?” in By No Extraordinary Means: The Choice
to Forgo Life-Sustaining Food and Water, ed. Joanne Lynn (Bloomington: Indiana University Press,
1986), pp. 117-31.
(n8.) James Rachels, “Active and Passive Euthanasia,” NEJM 292 (1975): 78-80; Michael Tooley,
Abortion and Infanticide (Oxford: Oxford University Press, 1983). In my paper, “Taking Human Life,”
Ethics 95 (1985): 851-65, I argue in more detail that killing in itself is not morally different from allowing
to die and defend the strategy of argument employed in this and the succeeding two paragraphs in the
text.
(n9.) Dan W. Brock, “Moral Rights and Permissible Killing,” in Ethical Issues Relating to Life and Death,
ed. John Ladd (New York: Oxford University Press, 1979), pp. 94-117.
(n10.) P. Painton and E. Taylor, “Love or Let Die,” Time, 19 March 1990, pp. 62-71; Boston
Globe/Harvard University Poll, Boston Globe, 3 November 1991.
(n11.) James Rachels, The End of Life (Oxford: Oxford University Press, 1986).
(n12.) Marcia Angell, “The Quality of Mercy,” NEJM 306 (1982): 98-99; M. Donovan, P. Dillon, and L.
Mcguire, Incidence and Characteristics of Pain in a Sample of Medical-Surgical Inpatients,” Pain 30
(1987): 69-78.
(n13.) Eric Cassell, The Nature of Suffering and the Goals of Medicine (New York: Oxford University
Press, 1991).
(n14.) Gaylin et al., “Doctors Must Not Kill.”
(n15.) Leon R. Kass, ‘Neither for Love Nor Money: Why Doctors Must Not Kill,” The Public Interest 94
(1989): 25-46, cf. also his Toward a More Natural Science: Biology and Human Affairs (New York: The
Free Press, 1985), chs. 6-9.
(n16.) Paul J. Van der Maas et al., “Euthanasia and Other Medical Decisions Concerning the End of
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Life,” Lancet 338 (1991): 669-74
(n17.) Susan M. Wolf, “Holding the Line on Euthanasia,” Special Supplement, Hastings Center Report
19, no. 1 (1989): 13-15.
(n18.) My formulation of this argument derives from David Velleman’s statement of it in his commentary
on an earlier version of this paper delivered at the American Philosophical Association Central Division
meetings; a similar point was made to me by Elisha Milgram in discussion on another occasion. For
more general development of the point see Thomas Schelling, The Strategy of Conflict (Cambridge,
Mass.: Harvard University Press, 1960); and Gerald Dworkin, “Is More Choice Better Than Less?” in
The Theory and Practice of Autonomy (Cambridge: Cambridge University Press, 1988).
(n19.) Frederick Schauer, “Slippery Slopes,” Harvard Law Review 99 (1985): 361-83; Wibren van der
Burg, “The Slippery Slope Argument,” Ethics 102 (October 1991): 42-65.
(n20.) There is evidence that physicians commonly fail to diagnose depression. See Robert I. Misbin,
“Physicians Aid in Dying,”NEJM325 (1991): 1304-7.
(n21.) Richard Fenigsen, “A Case against Dutch Euthanasia,” Special Supplement, Hastings Center
Report 19, no. 1 (1989): 22-30.
(n22.) Allen E. Buchanan and Dan W. Brock, Deciding for Others: The Ethics of Surrogate
Decisionmaking (Cambridge: Cambridge University Press, 1989).
(n23.) Van der Maas et al., “Euthanasia and Other Medical Decisions.”
(n24.) Margaret P. Battin, “Seven Caveats Concerning the Discussion of Euthanasia in Holland, ”
American Philosophical Association Newsletter on Philosophy and Medicine 89, no. 2 (1990).
~~~~~~~~
by Dan W. Brock
Dan W. Brock is professor of philosophy and biomedical ethics and director of the Center for Biomedical
Ethics, Brown University, Providence, RI.
Copyright of Hastings Center Report is the property of Wiley-Blackwell and its content may not be
copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written
permission. However, users may print, download, or email articles for individual use.
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