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Euthanasia Notes

Euthanasia has been a controversial topic for decades. It involves issues of patient rights, life and death, the
proper function of doctors, the ethics of suicide, and the overlap between law and morality.

Brain Death, Coma, and Persistent Vegetative State

In 1968 , an ad hoc committee of the Harvard Medical School was set up to establish criteria for determining
when someone is dead. This committee determined that someone should be considered dead if he has
permanently lost all detectable brain function. This condition is now known as whole brain death and is the
primary criterion used for the legal determination of death. Whole brain death is distinguished from other
conditions such as persistent vegetative state (PVS). In PVS, the individual has lost all cerebral cortex function
but has retained some good brain stem function. The result is that the individual in this state will never regain
consciousness but can often breathe naturally and needs no artificial aid to maintain circulation. A disconcerting
aspect of PVS is that patients in this state are unconscious but “awake.” In contrast, someone who is not totally
brain dead but who is in a coma is unconscious but “asleep.” His or her brain stem functions poorly, and thus this
person does not live as long as someone in a persistent vegetative state. If we use whole brain death criteria to
determine whether someone is dead, then neither a person in a persistent vegetative state nor a person in a coma is
dead. In these cases, euthanasia questions about whether to let them die can be raised. On the other hand, if
someone is dead by whole brain death criteria, then disconnecting equipment is not any form of euthanasia. We
cannot let someone die who is already dead.

Meaning and Types of Euthanasia

The term euthanasia has Greek roots and literally means “good death.” Euthanasia is of two types, Active and
Passive euthanasia. Passive euthanasia refers to stopping or not starting some treatment and letting a patient
die. The person’s condition causes his or her death. It is now a common practice and is not prohibited by law. In
recent years, many doctors, as many as 96%, have withdrawn or with-held life prolonging treatment for their
patients. Most of the time, this is done at the request of the patient or the patient’s family. In some cases, doctors
have done this on their own either without consulting patients or their families or even against their wishes. The
reasons given in either case were generally that such treatment would not extend the patient’s life for long or that
the patient’s life would not be worth lengthening such as when they were not expected to regain consciousness
( cases Karen Quinlan & Nancy Curzan page 139).
Active euthanasia is using certain death causing means to bring about or cause the death of a person. In the past,
it used to be called “mercy killing.” Drugs are the most common means. Rather than letting a person die, these
means are used actually to kill the person. This is generally regarded as much more problematic and is generally
legally prohibited.
Physician- Assisted Suicide
This issue is related to that of euthanasia because one form “ physician-assisted suicide” is a form of suicide. In
these cases, the physician does not actually inject a patient with a death causing drug as in active euthanasia, but
provides patients with drugs that they will take themselves. It is thus basically a form of suicide, with the doctor
providing the means to carry it out. Just as questions can be raised about whether suicide is ever morally
acceptable, so also can questions be raised about whether it is morally permissible for physicians or others to help
someone commit suicide. What is also different about doctor assisted suicide is that it involves doctors. It thus
jumps the barrier that prevents doctors from actually doing something that will cause the death of a person. In
some ways’ it looks like active euthanasia. ( case pathologist Jack Kevorkian page 141 last paragraph)
Pain Medication That Causes Death
One type of action may be confused with active euthanasia but ought to be distinguished from it: giving pain
medication to gravely ill and dying patients. Physicians are often hesitant to prescribe sufficient pain medication
to such patients because they fear that the medication will actually cause their deaths. They fear this would be
considered comparable to mercy killing or active euthanasia which is legally impermissible. Some philosophers
believe that the principle of double effect may be of some help here. According to the principle of double effect,
it may be morally permissible to administer a drug with the intention of relieving pain (a good effect) even though
we know or foresee that our action also may have a bad effect (weakening a person and risking his death). The
idea behind the double effect principle is that there is a moral difference between intending to kill someone and
intending to relieve pain. There is a moral difference between intending that someone die by means of one’s
action (giving a drug overdose) and foreseeing that they will die because of one’s action (giving medication to
relieve pain). Doing the latter is not, strictly speaking, active euthanasia.
Ordinary and Extraordinary Measures
Measures that are ineffective or excessively burdensome are called extraordinary by philosophers. There are
other cases in which what is refused would actually be effective for curing or making a life threatening condition
better. And yet decisions are made not to use these measures and to let the person to die. These measures are
called ordinary, not because they are common but because they promise reasonable hope of benefit. With
ordinary measures, the chances that the treatment will help are good, and the expected results are also good.
Voluntary and Nonvoluntary Euthanasia
In many cases, it is the person whose life is at issue who makes the decision about what is to be done. This is
voluntary euthanasia. In other cases people other than the one whose life is at issue decide what is to be done.
These are cases of non voluntary euthanasia. Non voluntary simply means not through the will of the
individual. It does not mean against their will. Sometimes others must make the decision because the person or
patient is incapable of doing so. This is true of infants and small children and a person who is in a coma or
permanent vegetative state also in cases of people who are minimally competent, as in cases of senility or certain
psychiatric disorders.
Moral Judgments about Euthanasia
One way to answer the question whether euthanasia of a certain type is morally justifiable is to use the distinction
made between consequentialist theories (such as utilitarianism) and nonconsequentialist theories (such as Kant’s
moral theory or natural law theory). If you think that it is the consequences rather than the nature of actions
themselves that matter morally, then you can focus on those considerations. If you think that we should judge
whether some action is right or wrong in itself for some reasons, then you can focus on non consequentialist
considerations and reasons.
The Moral Significance of Voluntariness
An individual’s rights over his or her own life are highly valued. Yet there are limits to it. It is limited, for
example, when it conflicts with the interests or rights of others. How important is voluntary consent?
Consequentialist Considerations
One major method of deciding moral right or wrong appeals to the consequences of our actions (act utilitarian) or
practices (rule utilitarian). From this perspective, voluntariness matters morally only to the extent that it affects
human happiness and welfare. Respecting people’s own choices about how they will die surely would have some
beneficial consequences. For example, when people know that they will be allowed to make decisions about their
own lives and not be forced into things against their will, then they will gain a certain peace of mind. These are
the good consequentialist reasons to respect a person’s wishes in euthanasia cases.
But it is not just the person who is dying who will be affected by the decision. Thus, it also can be argued that the
effects on others, on their feelings, for example, are also relevant to the moral decision making.
However, individual decisions are not always wise and do not always work for the greatest benefit of the person
making them or for others. For example, critics of euthanasia worry that people who are ill or disabled would
refuse certain lifesaving treatment because they lack or do not know about services, support, and money that are
available to them. On consequentialist grounds, we should do what, is most likely to bring about the greatest
happiness, not only of ourselves but also to all those affected by our actions. It does not in itself matter who
makes the judgment.
From the viewpoint of rule utilitarian thinking, we ought to consider which policy would maximize happiness.
Would a policy that universally follows individual requests about dying be most likely to maximize happiness?
Or would a policy that gives no special weight to individual desires, but which directs us to do whatever some
panel decides, be more likely to have the best outcome? Or would some moderate policy be best, such as one that
gives special but not absolute weight to what a person wants? An example of such a policy might be one in which
the burden of proof not to do what a person wishes is placed on those who would refuse it.
Non consequentialist Considerations
To appeal to the value of personal freedom in euthanasia decisions is to appeal to a nonconsequentialist reason.
The idea is that freedom is a good in itself and therefore carries heavy moral weight. We like to think of
ourselves, as masters of our own fate. According to Kant, persons are unique in being able to choose freely, and
this ought to be respected.
However, in many euthanasia cases a person’s mental competence and thus autonomy is compromised by fear
and lack of understanding. Illness makes a person more subject to undue influence or coercion. There is also a
high correlation between suicide and depression. “The most seriously depressed patients were twice as likely to
have considered suicide as all terminally ill patients. How in such instances do we know what the person really
wants? These are problems which arise when we attempt to respect autonomy.
ActiveVersus Passive Euthanasia
The moral question about Active and Passive euthanasia is: Is there any moral difference between them? Is active
euthanasia more morally problematic than passive euthanasia? Or are they on a moral par such that if passive
euthanasia is morally permissible in some cases then so is active euthanasia? Is physician assisted suicide any
more or less problematic than cases in which the physician actually administers the drug or uses other means to
bring about death?
Consequentialist Concerns
If we take the perspective of the consequentialist or act utilitarian, we should only be concerned about our actions
in terms of their consequences. The means by which the results come about do not matter in themselves. They
matter only if they make a difference in the result. So, if a person’s death is the best outcome in a difficult
situation, it would not matter whether it came about through the administration of a lethal drug dose or from the
discontinuance of some life saving treatment. But, if one or the other means did make a difference in a person’s
experience as when a person is relieved or pained more by one method than another, than this would count in
favor of or against that method.
If we take the perspective of a rule utilitarian, we would be concerned about the consequences of this or that
practice of policy. Which policy would have the best result overall. Which would be the best policy? One that
allowed those who were involved to choose active euthanasia, one that required active euthanasia in certain cases,
one that permitted it only in rare cases, or one that prohibited it and attached legal penalties to it? Which policy
would make more people happy and fewer people unhappy?
People are concerned in particular about the effects of physician participation in the practice of euthanasia.
Even, those who support physician assisted suicide and in some cases actual active euthanasia worry about
whether these practices would be open to abuse. The names given to this argument that there would be abuse are;
the “domino effect,” “wedge,” slippery slope,” “camel’s nose.” The idea is that if we permit active euthanasia in
some cases, then we would slide and approve it in more and more cases until we were approving it in cases that
were clearly unreasonable.
Non consequentialist Concerns
Arguments about the right to die or to make one’s own decision about dying are non consequentialist arguments.
On the one hand, some people argue that respecting personal freedom is so important that it should override any
concerns about bad results. Meaning that people should be allowed to end their lives when they choose as an
expression of their autonomy or freedom, and this choice should be respected regardless of the consequences to
others or even mistakes about their own cases.
On the other hand, some people believe that there is a significant moral difference between killing another person
or letting a person die. Killing people except in self defense is morally wrong, according to this view. Just why it
is thought wrong is another matter.
Reasons as to why killing is wrong are similar to those given by natural law theory, citing the innate drive
towards living as a good in itself, it shouldn’t be suppressed. Kant also argues on similar grounds. Some people
use religious reasons such as the belief that life and death decisions are for God and not ourselves to make. Others
use reasons that rely on concerns about the gravity of ending a life directly and intentionally, that in doing so we
ally ourselves with what is at best a necessary evil.
Ordinary Versus Extraordinary Measures
There is a disagreement about the use of these terms. If the terms mean commonness and uncommonness, then it
is difficult to see how this makes a moral difference. But if the terms are defined in terms of benefit and burden,
then that is relevant as these are moral terms. The question which arises is how to measure these benefits and
burdens. Is financial cost to a family or society a part of the calculation? The danger of including the effect on
others in the calculation and not just the benefits and burdens to the patient herself . is that we might say some
people should die because the burden of taking care of them is just too great. If we know what are ordinary and
extraordinary measures in a particular case, we would be able to decide whether there is good reason to provide
the measures. If we judge them ordinary then they ought to be provided, if we judge them extraordinary then they
probably need not be provided.
Infant Euthanasia
Every few years, a case of disputed life and death decisions regarding an infant seems to appear in the news. The
cases which have drawn the most criticism are cases like the one in which an infant born with Down’s syndrome
was left untreated and died. Down’s syndrome is a genetic anomaly that causes mental retardation and sometimes
physical problems as well. In this case, the child had a repairable but life threatening blockage between the
stomach and the small intestines. The parents refused permission for surgery to repair the problem, and the
doctors followed their wishes and let the infant die. Critics of this case protested that this surgery was simple and
effective, and the infant, although retarded, could lead a generally happy life.
Not to treat in such a case has been interpreted as not using what would be considered ordinary means of life
support, ordinary because the benefits to the patient would outweigh any burdens. Such cases have been criticized
for their buck passing, that is, shifting responsibility for the death to nature, as though in this situation but not
elsewhere in medicine we should “let nature take its nature.” Because the infant is not able to express his wishes,
these will always be cases of nonvoluntary euthanasia.