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�EUTHANASIA - AN ETHICAL ISSUE

Dipa Chakraborty

P.N.Das College

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Some Initial Distinctions

Active vs. Passive Euthanasia
Voluntary, Non-voluntary, and Involuntary Euthanasia
Assisted vs. Unassisted Euthanasia

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Active vs. Passive Euthanasia

Active euthanasia occurs in those instances in which someone takes active means, such as a lethal injection, to bring about someone’s death;
Passive euthanasia occurs in those instances in which someone simply refuses to intervene in order to prevent someone’s death.

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Criticisms of the Active/Passive Distinction in Euthanasia

Conceptual Clarity

Vague dividing line between active and passive, depending on notion of “normal care”
Principle of double effect

Moral Significance

Does passive euthanasia sometimes cause more suffering?

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Active Euthanasia

Typical case for active euthanasia

there is no doubt that the patient will die soon
the option of passive euthanasia causes significantly more pain for the patient (and often the family as well) than active euthanasia and does nothing to enhance the remaining life of the patient, and
passive measures will not bring about the death of the patient.

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Voluntary, Non-voluntary, and Involuntary Euthanasia

Voluntary: patient chooses to be put to death
Non-voluntary: patient is unable to make a choice at all
Involuntary: patient chooses not to be put to death, but is anyway

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Assisted vs. Unassisted Euthanasia

Many patients who want to die are unable to do so without assistance
Some who are able to assist themselves commit suicide with guns, etc.--ways that are much harder and difficult for those who are left behind.

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Compassion for Suffering

The larger question in many of these situations is: how do we respond to suffering?

Hospice and palliative care
Aggressive pain-killing medications
Sitting with the dying
Euthanasia

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The Sanctity of Life

Life is a gift from God
Respect for life is a “seamless garment”
Importance of ministering to the sick and dying
See life as “priceless” (Kant)

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The Right to Die

Do we have a right to die?

Negative right (others may not interfere)
Positive right (others must help)

Do we own our own bodies and our lives? If we do own our own bodies, does that give us the right to do whatever we want with them?
Isn’t it cruel to let people suffer pointlessly?

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Two Models

A utilitarian model, which emphasizes consequences
A Kantian model, which emphasizes autonomy, rights, and respect

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The Utilitarian Model

Goes back at least to John Stuart Mill (1806-73)
The greatest good for the greatest number

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Main Tenets

Morality is a matter of consequences
We must count the consequences for everyone
Everyone’s suffering counts equally
We must always act in a way that produces the greatest overall good consequences and least overall bad consequences.

When we ask what the right thing to do is, whether in a clinical situation or in everyday life, one of the things we all look at are consequences. When we consider enacting a piece of legislation, we ask about the consequences. Who will this harm? Who will this help? How much? Similarly, I assume you ask similar questions when considering treatment options? What are the relative benefits and harms of the various alternatives?

In moral philosophy, this way of thinking is generally called utilitarianism. The key notion of utilitarianism is that morality is a matter of consequences; furthermore, utilitarians agree that the right thing to do is what produces the best consequences for everyone. John Stuart Mill was the most influential utilitarian thinker. He gave us what is called the Greatest Happiness Principle, which “holds that actions are right in proportion as they tend to promote happiness, wrong as they tend to produce the reverse of happiness.”

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How much care should be given at the end of life?

Health care providers are increasingly concerned, not just about how much money is spent on patients, but about how effectively it is spent.
Disproportionate amount of money spent in final months of life.

40 percent of Medicare dollars cover care for people in the last month.
Nearly one third of terminally ill patients with insurance used up most or all of their savings to cover uninsured medical expenses such as home care.

Concept of medical futility is utilitarian in character.

How much care should be given at the end of life? As I’m sure all of you here know, an inordinately high percentage of our medical dollars go to treatment during the last months of life, and this is a concern to everyone. It is important to be precise about why this is a concern. For most of us, it is not a concern solely because so much money is being spent, but rather because we feel it is not always being well spent. We are not getting a lot back for our money, and we could get a much higher return on our dollars if they were spent in more cost-effective ways. Here the lure of preventive medicine and wellness programs is particularly important insofar as they seem to offer the possibility of spending these dollars in ways that will have a far greater overall impact of the quality of life.

This is a prime example of utilitarian thinking. It looks at consequences, and it seeks the course of action that will produce the greatest overall good consequences and the least overall harmful consequences. The concept of medical futility, an increasingly important concept during the last ten years, is essentially a utilitarian one. It looks at consequences and attempts to draw a clear line at that point where treatment no longer holds a reasonable hope of producing good consequences.

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What is a good death?

Jeremy Bentham.�Hedonistic utilitarians: a good death is a painless death.

Eudaimonistic utilitarians: a good death is a happy death.�John Stuart Mill

What is a good death? One of the issues for utilitarians has been how you measure “good consequences.” What is the standard, the yardstick, in terms of which these can be measured? What is the scale that we can employ? Two standards have vied for supremacy in utilitarianism, and these two standard compete at well in how we understand what a good death is.

John Stuart Mill, whom I mentioned earlier, said that happiness is the appropriate measure of consequences. In doing so, he was breaking from the work of his immediate predecessor, Jeremy Bentham. Bentham maintained that pleasure was the appropriate measure of consequences, and those alternatives that produced the greatest amount of pleasure were the right ones. Mill, despite his personal liking for Bentham (who was in fact his godfather), called this a “pig’s philosophy.” Pleasure, he maintained, was too gross, too bodily a standard for human beings; we must instead look to what produces happiness, not mere pleasure.

This is, of course, a choice we face many times a day. If I want to fix my daughter the breakfast that will give her the most pleasure, sugar and chocolate would probably be the principal components. If I want to fix her a breakfast that will give her the most happiness, presumably a nutritionally more balanced alternative will result in more happiness. Or, even more bluntly, heroin give you pleasure, but it doesn’t give you happiness.

This battle about standards plays itself out in regard to end of life decisions as well. Let me indicate one way. What is a good death? Those who think in terms of pleasure identify a good death as one that is without pain. Modern medicine can do a lot to eliminate, or at least reduce, pain. Those who think in terms of happiness view a good death as more than pain-free. The work of Elizabeth Kubler-Ross was pioneering in helping us to understand the stages of dying and to see what might be involved in a good death. Today hospice often leads the way in understanding what a good death is, and it goes far beyond the mere absence of pain. It often involves developing a sense of closure about one’s life, reconciliation with family, and peacefulness.

Those utilitarians who see a good death along the pleasure-pain axis are, I think, most likely to think it is better just to “end someone’s suffering,” to put them out of their misery. The crucial concern is physical pain. One of this morning’s case studies, “It’s over, Debbie,” is an example of this. The resident’s concern was simply to end Debbie’s pain.

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Types of Rights

Two types of rights

Negative: imposes duties of non-interference on others
Positive: imposes duties of assistance on others

Health care (including end-of-life care) as a right:

Negative right. Widespread agreement on this.
Positive right. Much disagreement. Do people have a right to health care even when they can’t pay? On whose shoulders does the duty fall?

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Conclusion

Many of the ethical disagreements about end-of-life decisions can be seen as resulting from differing ethical frameworks, esp. Kantian vs. utilitarian.
Use these models to understand where you stand, where your patients stand, and where your organization stands in regard to end-of-life issues.