Medical Ethics PHIL 148 @ Binghamton University, Sum 11

18Jun/1115

Euthanasia Debate

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Question: If one terminal cancer patient refuses necessary life-sustaining treatment and another terminal cancer patient purposefully takes a fatal dose of necessary painkillers for managing the pain of the cancer, are these two circumstances of death morally different?

Position: Morally speaking, there is no difference between refusing life-sustaining treatment and taking a fatal dose of painkillers. The patients who make one of these two choices have decided that they want to die. Yes different methods are being used but the final outcome will be the same, and both patients have the knowledge and understanding of the outcome of their decision. Is it immoral for a patient to choose the way in which they die? This is a part of their autonomy. As long as the doctor is not the one who administers the fatal dose of painkillers and it is the patient who takes the dose on their own accord, it remains within moral boundaries.

The key point in this case is that both patients are terminally ill, meaning they will eventually die. The patient who chooses to actively ingest the fatal dose of painkillers merely chooses to die sooner and feeling no pain, while the other patient chooses to die naturally. As a healthy person watching from the sidelines it is easy to dictate what we think is wrong or right in this delicate situation. However we cannot place ourselves in their position. Suffering from a terminal condition may make a person readjust their idea of what is wrong or right in terms of euthanasia. According Hwang we currently have a cultural antipathy towards active euthanasia, or suicide as he calls it, is largely because of Western Christian influence. He goes on to say that quality of life is important and that the decision to end ones life because of intolerable conditions can be a sane and dignified option that is the thoughtul result of reasoned judgemnt (Hwang, paragraph 5).

Since these patients are terminally ill, continuing to live would be a burden on medical resources and the medical staff. Continuing their treatment would only delay their death and perhaps prolong their suffering and even the suffering of their loved ones who are taking care of them. In fact, Hardwig would suggest that it is not onlymoral for them to choose one of the cited options of euthanization but that it is an obligation. They have a duty to die. Therefore, there is no moral difference in choosing passive or active euthanization. Both result in the same outcome and both are a direct and autonomous decision of the patient.

17Jun/1127

Euthanasia Debate

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Question: If one terminal cancer patient refuses necessary life-sustaining treatment and another terminal cancer patient purposefully takes a fatal dose of necessary painkillers for managing the pain of the cancer, are these two circumstances of death morally different?

Position:

There is a moral difference between refusing treatment and taking a lethal dose of medication. Both situations are voluntary euthanasia; the major distinction is that the first is classified as passive euthanasia while the second is active euthanasia. The moral distinction according to Callahan would be that active euthanasia is killing while passive euthanasia is letting the person die. Although the end result is the same they are morally different. In one case you are adding something to cause death while in the other you are removing something to let the person die however they would in nature. In active euthanasia you are doing something to cause the death of the person while in passive euthanasia you are letting something happen, that isn’t your fault, which will result in the person’s death. While it can be agreed upon that killing another person is wrong, it can be said that letting a person die when there is no possible chance of cure or treatment is never wrong.

In the case of active euthanasia another person’s involvement to some degree is required. Unless the person steals the drugs used to end their life they had to get them from someone, usually a doctor. This request for the drugs to end their life would be a demand of treatment which the doctor does not have to respect or follow. This also has the possibility of creating a moral conflict for the doctor which would be morally wrong for the patient to do. This agrees with care ethics which would disregard the autonomy of the patient in exchange for caring for the patient and the interpersonal relationship with their health care professionals especially doctors. Refusal of treatment has the possibility to involve no one, although comfort measures are often taken which would involve health care professionals. The doctor also has an obligation to respect the wishes and autonomy of the patient who is informed and understands the implications of their refusal.

There is also the controversial argument that in some cases active euthanasia may actually be the more merciful option. In some cases comfort measures are not sufficient enough and do not provide the necessary relief from pain that would make passive euthanasia bearable. In these cases it can be argued that it is morally wrong to let that person suffer through the process of passive euthanasia. While passive euthanasia can take days, weeks, months, or years, active euthanasia provides immediate relief from suffering. This of course depends on the euthanasia being voluntary and the patient being well informed of all their options and competent to know what is right for them removed from any outside pressures.

16Jun/1128

News Article: Euthanasia

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French Woman Who Sought Euthanasia Dies

What would you do if you were faced with a medical crisis that was both terminal and painful but did not have the legal consent to perform voluntary active euthanasia? Would you just accept your fate or would you do something to change it? How would you react if you knew that the country that you loved so dearly denied you of this luxury and watched as you suffered with this unbearable illness until your dying day? What would you do then? Would you be subjected to suicide (in physically taking your own life) or would you endure in an excruciatingly painful death (that can otherwise be viewed as passive euthanasia)?

No one really knows what happened that day. Chantal Sebre was found dead in the chambers of her own home in the French town of Plombieres-les-Dijon in eastern France one Wednesday afternoon. According to the news, she was only 52 years old and was suffering from a very rare form of cancer called esthesioneuroblastoma. As rare as they come, the effects of this illness was said to have contributed to her lost of eye sight, nose and tastes senses during the last eight years of what appeared to have been her miserable life. What make matters even worse is that the excruciating pain that Sebre felt in her eye (for the tumor had caused her nose to swell several sizes beyond its original size and her eye to be pushed out of its socket) could not be contained by morphine because of its dominant side effects. This led Sebre to the only possible choice she felt had; the only choice that could stop her physical and mental torture for good: active euthanasia. The French courts, however, denied this request and that is what, I believe, led to her death (local authorities are still unsure of how she died).

What attracted me to this news article was the “before and after picture” that accompanied it. The facial tumor had completely disoriented this woman’s face and I was curious about the story that followed. One could only imagine the amount of pain she endured by just looking at the photo. Despite the fact that her autonomy was completely disregarded this case also makes me question the moral and medical ethics behind the practice of French doctors. It’s understandable that in this country the practice of euthanasia is not encouraged or enforced but something could have certainly been done to relieve this patient of her pain. I mean isn’t that what medial subjects are suppose to do? Aren’t they suppose to find other alternatives to the current problem? The news article doesn’t really go into detail but it appears as if she received a court order stating that she couldn’t be grants rights in taking her own life and was just left to die (without the help any physician). This clearly dissatisfies the viewpoints of self-determination in Brook’s argument about the use and need for euthanasia. His concept clearly justifies autonomy but I wonder if it would be safe to say so in this case because of the fact euthanasia isn’t practiced at all in France?

Reading this article also brought another interesting concept to mind. Because the news article doesn’t state the exact cause of death I assume that one is granted permission to make assumptions about how Seibre died. If she were to have proceeded into taking her own life by say an overdose of pills, would it be wrong to describe the act as voluntary active euthanasia? After all, according to Gay and Williams’ definition of euthanasia one must have intentionally engaged in an act that is intended to lead to death. Therefore, will it be flawed to say that suicide and active euthanasia was essentially the same thing? If they are both medically induced by the uptake of drugs then what is the distinction?

16Jun/1124

News Article : Euthanasia

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http://news.google.com/newspapers?id=gVUlAAAAIBAJ&sjid=ieUFAAAAIBAJ&pg=5828,2129559&dq=euthanasia&hl=en

This news article is from the Ottawa Citizen, a Canadian newspaper, from 1962 and is still relevant to this weeks ethical issues surrounding euthanasia. Suzanne Vandeput a 24-year-old woman was found guilty for murdering her 8-day-old baby. The baby was born with birth defects due to thalidomide poisoning. Thalidomide was a sedative drug used in the 1950’s until it was recalled in 1961, because it was found to cause birth defects. Suzanne’s baby was born without arms and deformed feet. Not only was Suzanne found guilty but also her husband, sister, mother and doctor were charged with complicity in the case. According to the article, the doctor gave barbiturates to the grandmother, and the mother administered them to the newborn.

I believe this news article shows the downside of euthanasia. When autonomy for the person losing their life is not accessible. This child had no choice or chance for survival in the world, with family members and doctors deciding what is the right decision for them. The prosecutor used the argument that other than her deformations the baby “was fit to live”.  However from the mother and doctor’s perspective the newborn’s malformations would have caused her grave suffering for her entire life and so the decision was made for her.  Hwang’s statement in “Rational suicide and the Disabled Individual” state that the disabled are able to make rational decisions when deciding to die, if this child were given the option to live for instead a few years rather than 8 days, the child would be able to decide if the emotional and physical pain was worth enduring in exchange for continuing her life.

I chose this article because it not only shows the downside to euthanasia it also shows how the responsibility falls on those who assisted in the euthanasia. The doctor took part in active euthanasia, as well as, non-voluntary euthanasia. This was done in Belgium, which now interestingly enough has legalized euthanasia, but at this time it was illegal, hence why all the parties involved were charged. The article is also about how the jury, even though they found the defendants guilty, asks for leniency in charging them.  So, at the time even though it was illegal, the jury could see some justification for the defendants’ actions. Normally, I would understand a jury showing leniency for someone defending passive euthanasia, but for what the mother called “mercy killing” seems a little to compassionate for murder.  Non-voluntary euthanasia gives rise to problems surrounding euthanasia because it removes the patients self-determination, autonomy, and life without consent. In some cases, not saying this one, non-voluntary euthanasia is seen as morally ethical.

The prosecutor states, “ They never seriously examined the chances of the child in this world which struggles to alleviate suffering. You cannot acquit them”. I found this interesting because it shows that the prosecutor recognizes the child will have to go through hardships to stop the pain whether it is physical or emotional. So it seems the prosecutor values life over pain and suffering.

Some questions to consider…Would you support euthanasia of a newborn knowing that the rest of the child’s life would be full of pain? Should the Doctor be charged more harshly than the rest of the family members? Should the family members be blamed more harshly for not getting a second opinion? Should we support technology that enables pregnant woman to see if their child would be born with birth defects during the period that is still legal to have an abortion?

 

16Jun/1121

News Article: Euthanasia

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Immigrant's Health Crisis Leaves Her Family on Sideline

Rachel Nyirahabiyambere, age 58, has been in a persistent vegetative state ever since she had a stroke in April of 2010. In February, her feeding tube was removed based on the decision made by her court-appointed guardian, Andrea Sloan.

What makes Rachel's case unique is the fact that because she is a recent immigrant to the United States and she has been here for less than five years, she is ineligible to receive Medicaid and thus, is uninsured. Prior to her stroke she was employed at a nursing home and received medical benefits, however, she had to leave this job (and lose the health insurance) when she moved to provide childcare for her grandchildren.  After her stroke last April, Rachel remained in a vegetative state at Georgetown University Hospital for about seven weeks; at which point the hospital began attempting to discharge her and instructed her family to locate a nursing home for her or to hire in-home care.  When her family was unable to provide the funds for this because she was uninsured, they found themselves in a precarious situation with the hospital.  In November of 2010, the hospital took action to give Rachel a court-appointed guardian; although her sons fought to retain control over their mother's care, Ms. Sloan was appointed as guardian and soon transferred Rachel to a nursing home after getting the hospital to cover the costs (an option that was not given when Rachel's family had initially came into conflict with the hospital).   Ms. Sloan then placed Rachel in hospice care and decided to have her feeding tube removed February 17th and as of March 3rd when this article was published, Rachel was still alive.

An update to the story

Rachel's feeding tube was reinstated after an advocacy group petitioned a Virginia judge on behalf of Rachel's family deciding that the tube be reinstated until all of the legal issues were sorted out.

Wow, I'm sorry if my summary was a bit on the long side, but I had to read the article a few times to get the facts straight since it jumped around a bit, so I thought it might be helpful to lay it all out chronologically 🙂  I chose this article because I found the case to be pretty unique, compared with many of the examples and cases given in this week's readings.  I think most of us have come to agree that in cases where a patient is unable to make decisions, that decision making power should automatically be given to the family. Yet, in this case, it seems like because of Rachel's family's inability to pay for her care-- they were legally denied this decision making power.  And as a consequence, Rachel's feeding tube was removed against their wishes.

Is this fair? Is this even ethical?

I think that from a utilitarian perspective, Ms. Sloan's decision would likely be supported.  Given the fact that Rachel is unlikely to make any sort of recovery, the utilitarian would say that Rachel is using resources that could be better directed to other patients with better chances. Additionally, given Rachel's state, her family is likely to already have undergone some degree of a grieving process similar to the process one goes through when someone passes away.  Letting go of Rachel and removing her from the feeding tube may actually help her family in coping with their loss. This would all be likely permissible under rule-utilitarianism especially since Ms. Sloan was appointed guardian by the court.  I feel that the deontological perspective might offer a very different analysis of this situation.  Given that it is extremely unclear as to what Rachel would have wanted, Ms. Sloan may be perceived as seriously encroaching on Rachel's dignity by making this decision without any clear evidence of her wishes. I believe that Ms. Sloan is also violating a respect for the views of Rachel's family in the matter and thus, her actions would likely be deemed unethical from deontological standpoint.

  • Are there any other philosophical perspectives that would offer a clear ethical solution to this case?
  • Do you have any disagreements with my analysis or additional aspects to add that I haven't considered? Feel free to share 🙂

This article really reminded me of the points brought up this week's reading, Hwang: Rational Suicide and the Disabled Individual-- Hwang made a point of discussing how social influence can have a huge bearing on the way ethical "right-to-death" issues are handled.  Although nonvoluntary euthanasia wasn't expressly mentioned, a few of the cases mentioned dealt with disabled people (wishing to engage in both PAS/AAS) whose quality of life was decreased many times due to the lack of funding that they received. For me it raised questions about whether or not it was justifiable for society to drive people into such an unfortunate state, and then consent to their "right to die." The connection may not seem that clear, but had Rachel been able to receive Medicaid, her family would have been free to keep her on life support as long as they needed/wanted without any legal struggle. Yet, in this respect because of Rachel's citizen status she and her family were failed by the system. Leading her family to be pressured by the hospital and court to make a decision and when they were unable to, someone was assigned to do it for them.

  • Does this case have the potential to set dangerous precedents in the future?
  • Where is economic reasoning's place within ethical decision making? Should it even have one?
  • After reading the article, were you able to discern any possible conflicts of interests in the case?
  • Had you been Rachel's family, how would you have reacted to the guardian being appointed by the court and does this have any bearing on your opinion about the case?
15Jun/1118

News Article: Euthanasia

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http://www.thisislondon.co.uk/news/article-23385278-i-want-to-die-its-my-human-right.do

 

Kelly Taylor is a 30 year woman living in England who is given less than a year to live. Kelly suffers from a heart and lung condition Eisenmenger's syndrome and Klippel Fidel syndrome a spinal condition. Kelly is allergic to every drug that is normally treated to relieve the pain that comes with having Eisenmenger's syndrome and her doctors are unable to find any medication that can help her. The only thing that could help her condition is a heart-lung transplant, she was on the waiting list for nine years, but unfortunately two years ago she was removed from the list because her body has become so weak that it would be hard for her to survive from such a great operation. She has decided to have her morphine dosage increase tremendously which would either leave her in a coma or dead.  Secondly she has a living will; this would require her physician to withdraw any form of food or hydration from her. However her doctors refused to carry out Kelly's wishes and thus a court case is in the making. Kelly wants the English law to change, allowing terminal ill patients to have a choice of choosing to end their lives.

Kelly Taylor is expressing both passive-voluntary and active-voluntary euthanasia; voluntary meaning a purposeful death by consenting to die. Her fist method is a form of active-voluntary euthanasia because she is using drugs in order to cause her death. While her second form of death is passive due to the fact that she wants to have her food and hydration withdrawn. I do think that Kelly should be able to make this decision regarding ending her life solely because she is in constant pain and there is nothing that her doctors can do to help. She stated “I have had enough of life - well, I don't know whether I have had enough of life but I have had enough of my illness. I have made the decision because enough is enough. I'm just hanging on. I don't want to be here, I don't want to suffer any more.” Indeed Kelly is suffering, and she just wants the pain to end and thus she believes that ending her life is her only escape.

There are several ideas that support euthanasia; one is individual self-determination as used by Brock.  This allows people to take responsibility for their lives and for the kind of person they want to become. It holds a strong value because it allows people to live in accordance to their definition of a good life. Thus Kelly is merely exercising her self-determination; she is choosing to end her life. In addition Hardwing states that we may have a duty to die when the burden of caring for us seriously burdens the lives of those who care for us. In Kelly’s case her sickness is a burden on her husband because he is the one who has to constantly take case of her and bring her to her doctor’s appointments.

Autonomy and Act-Utilitarianism plays a role in euthanasia as well. It is vested in her autonomous duties for her to take control of her life and what she wants to do with it. In addition act-utilitarianism is defined as the best action that produces the maximum utility, in this case the maximum utility is granting Kelly the right to die. She wants to die and her Husband is with her 100% in her decision this indeed creates the greater happiness.

Do you think that euthanasia can be viewed as ending pain and not necessarily death?

Filed under: Euthanasia 18 Comments
15Jun/1129

Case Study: Euthanasia (Deontology)

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Emma Ogden has been suffering from a persistent heart defect her whole twelve-year-old life.  Dr. Abdul Hamid conveys to her and her parents that the only chance of survival that Emma has is a risky heart transplant procedure.  Emma, who is mature for her age, decides that she does not want to go through with the procedure and accept the consequences which would be  death.  Dr. Hamid is startled and wants to treat her but is stuck.

In deontology, morality is based on what one's duty is and doing one's duty.  In this case, the duty of the physician is to go through whatever channel he can and see to it that the heart transplant takes place.  Dr. Hamid must overlook the fact that Emma has stated that she does not want the heart transplant; after all, Emma is still a minor.  How can a twelve-year-old know what's best for her in a field that makes their students study for practically twelve years.  Dr. Hamid does have a duty towards the parents of Emma since she is a minor.  He needs to talk to Emma's parents and get the consent to go through with the procedure.  According to deontology, I feel that Dr. Hamid's duty towards Emma's parents is less important than his duty as a physician.  If consent cannot be obtained, Dr. Hamid's duty still doesn't change in performing the operation.  He must then, like the last sentence of the case study says, obtain a court order giving him permission to operate against the wishes of both the girl and her parents.

In Kantian deontology, we have what is called perfect duties.  Essentially, a perfect duty is one that does not go against natural.  Of the numerous perfect duties, there are three that stand out: do not kill, do not lie, and the duty to keep promises. The third and final perfect duty that Kant believes is most relevant here.  When Dr. Hamid became a physician, he took the Hippocratic Oath.  In that Oath, he specifically pledged that he would "...apply, for the benefit of the sick, all measures that are required..."  By finding a way to operate on Emma, Dr. Hamid would be upholding the truths that he pledged to years ago.

In Rossian deontology, we have what is called prima facie duties.  Prima facies duties are different from Kant's perfect duties and imperfect duties in a sense that a perfect duty can be transgressed in order to obtain an imperfect duty or rather a greater good.  Dr. Hamid's prima facie duty is to go against the family's wishes in order to obtain permission a court order giving him permission to perform the heart transplant.  The greater good here is the heart transplant since it will give Emma the best chance of survival, and so, according to Rossian deontology, Dr. Hamid must see to it that it takes place.

What are Dr. Hamid's main duties?

What are your ethical views on this case?

Do you guys agree with Kantian deontology in this specific case?

Do you guys agree with Rossian deontology in this specific case?

 

 

15Jun/1113

Case Study 6/15 Sam Ahmed (Care Ethics)

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The main conflict in this Case Study is whether or not Doctor Hamid should push for the heart transplant even though the  12 year old patient Emma, wants to forgo the procedure.  The patient realizes that the procedure would not guarantee her full recovery stating that there is “10-20 percent chance at 5 year survival”.  Emma has gone through so many previous procedures and much to her dismay still has complications with her heart.  Emma also has already convinced her parents to follow her wishes although she condemns herself to death.  In Emma’s eyes, passive euthanasia, or the denial of any further treatment to “let nature take its course” to a natural death is worth more to her rather than going through another intense procedure and the grueling path to recovery.

Taking the stance of Care Ethics, the doctor must consider the relationships at stake rather than trying to justify his actions through some sort of moral code or standard as most other ethical theories do.  I believe that if the Doctor must show true empathy and compassion for other or his patient, Dr. Hamid must respect both Emma’s and her parent’s wishes.  It is not hard to understand why Dr. Hamid was “taken aback” by Emma’s request to deny treatment, essentially because no health care professional wants to let their patient die.  Dr. Hamid must relate to Emma’s situation and sympathize with the fact that she has undergone a myriad of treatments already and although some were successful, she still suffers from her heart condition.  If Dr. Hamid wants to truly retain the relationship between Emma and her parents, as proponents of Care Ethics argue, then Dr. Hamid cannot request a court order for the procedure.  Again, I realize that this goes against almost all beliefs as a doctor, and under any other ethical perspective this seems drastically immoral, under care ethics it is the relationships in certain situations which must be considered.  Care Ethics also allows individuals to be interdependent on attaining their interests, and in this case Emma’s interests are to forgo the transplant and stop fighting the condition.

 

What other obvious ethical perspectives’ does this decision go against?

Do you think there is an alternative solution? (still maintaining a strong patient professional relationship)

How would you act if Emma was your child?

13Jun/110

Week 03>Quiz

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Euthanasia

This week we covered euthanasia and physician-assisted suicide--including discussions of the distinctions between voluntary and nonvoluntary, and active and passive euthanasia. Test your knowledge of the readings using the quiz.

After you've completed the quiz, email the instructor the percentage answered correctly and receive full credit.

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12Jun/1126

Lecture 06/13>Euthanasia and Assisted Suicide

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The main moral question for this week is: Is it ever morally right to take a life?

As with any of the questions in this course, the devil is in the details and this single question is complicated by a host of distinctions.  First, we are, as is appropriate to medical ethics, focusing on this question within the medical field, so this question is narrowed to the question: what medical circumstances justify taking a life?  Is terminal illness all?  Or severe chronic pain? Or life-altering disability?  Euthanasia comes from the Greek and means (literally) "good death."  The main idea behind euthanasia is that control over the circumstances and time of one's death are critical no only to having a good death, but having a good life.

There are different sorts of "taking a life."  And these distinctions are taken to be morally relevant.  I want to concentrate on these distinctions in this week's lecture.

Voluntary, Non-Voluntary, and Involuntary Euthanasia.  These three terms refer to three distinct relations of the patient to their death.  Voluntary euthanasia is purposeful death where the patient has consented to die.  Non-voluntary euthanasia is purposeful death where the patient is unable to consent to die (think persistent vegetative state or other forms of lower functioning).  Involuntary euthanasia is purposeful death where the patient has expressed a desire not to die.  The focus of arguments will not be on this last one, as it is extremely problematic.  Where voluntary and non-voluntary euthanasia both have vocal proponents, involuntary euthanasia has very little support (for reasons you can fill in on your own).  However, see Hardwig's article for one line of thought that could lead to involuntary euthanasia, although this is not what Hardwig is arguing for.

Active and Passive Euthanasia. The distinction drawn between active and passive euthanasia is the form of dying.  In active euthanasia, drugs or another direct form are applied in order to directly bring about the patients death.  In contrast, passive euthanasia involves the removal of life support or other forms of care and allowing a disease, injury, or other damage to the body to take its course.  In passive euthanasia, it is argued that the actions of those involved only indirectly cause the death of the patient.

Physician-Assisted Suicide. This is simply a subclass of euthanasia that refers to the assistance of medical staff in the death of an individual.  The term euthanasia is generally used to refer to any form of purposeful death to end pain or suffering.  Thus, euthanasia can be performed by anyone: the patient, a family member, a friend, a stranger.  What is important about physician-assisted suicide (PAS) is the role of the medical professional in the death.  It does not have to be a direct role.  While directly injecting drugs into a patient's system or unhooking life support fall under PAS, so does writing a prescription for the patient to take on their own.  The main concern in PAS is the particular moral issues that arise from a medical professional taking part in ending a life.

Over the course of your readings, these distinctions are given different emphasis--largely focused on active versus passive euthanasia and PAS.  The active/passive distinction is controversial because the end and intention are the same.  Refusal of hydration and nutrition further complicates matters.  One of the main arguments in favor of passive over active euthanasia is that passive is simply "letting nature take its course."  Yet, one could argue that starvation is equally "natural."  Is refusal of hydration and nutrition passive or active?  And if it is passive, is it as equally justified as a patient going off life support?

PAS is controversial because there is a question of the proper role of medical professionals.  Are they meant to preserve life at all cost?  Are medical professionals supposed to do no harm?  What constitutes doing harm?  Some argue that euthanasia is fine, but physician-assisted suicide is extremely problematic because of the role of medical professionals.

Key Concepts:

  • Voluntary Euthanasia
  • Involuntary Euthanasia
  • Non-voluntary Euthanasia
  • Active Euthanasia
  • Passive Euthanasia
  • Physician-Assisted Suicide

Some Questions to Consider:

  • Are active and passive euthanasia different?
  • What is the proper role of medical professionals?
  • How could involuntary euthanasia be justified?
  • How much does control over one's own body impact discussions of euthanasia?