End Of Life

Question 1

possible issues in end of life ethics

Answer 1

Active vs Conservative?

Harm vs Benefit?

Duties, what is the doctor’s motive?

Role of relatives/patient’s wishes

Question 2

acts and omissions

Answer 2

Omission = to withhold medical intervention

Act = to carry out a medical intervention

If the consequences are the same is there a moral distinction?

Is the morality in the behaviour or in the consequence?

Question 3

Airdale Trust vs Bland [1993] AC789

Answer 3

Lord Mustill:
“the English criminal law… draws a sharp distinction between acts and omissions. If an act resulting in death is done without lawful excuse and with the intent to kill it is murder. But an omission to act with the same result and the same intent is in general no offence at all.”
Airdale NHS Trust v Bland [1993] AC789

“There is one important general exception at common law, namely that a person may be criminally liable for the consequences of an omission if he stands in such relation to the victim that he is under a duty to act.”

Question 4

Withdrawing and Withholding

Answer 4

Both are classed as omissions to act in the eyes of the law

Usually thought of in the context of non-capacitous patients

Remember an informed capacitous patients can decline any medical treatment at any time – Re: Ms B

Question 5

Elective Non Treatment

Answer 5

Do doctors always have to treat?

If not, what criteria might have to be met?

Question 6

Burke vs GMC [2005]

Answer 6

If a patient asks for a treatment that the doctor does not offer, and the doctor has concluded that the treatment is not clinically appropriate, then the doctor is not obliged to provide it, but should offer a second opinion.

Question 7

Ordinary and Extraordinary (treatment)

Answer 7

ORDINARY

• Outcome likely to be satisfactory
• Reasonable cost
• Not too painful/burdensome
• Common practice/routine

EXTRAORDINARY

• Involved greater expense
• Pain
• May be dangerous
• Unusual
• Difficult
• Not obligatory
• Greater burden to patient/family.
• Without reasonable hope of successful outcome

Question 8

GMC Guidance

Answer 8

“Not continuing or not starting a potentially life-prolonging treatment is in the best interests of a patient when it would provide no net benefit to the patient”

Withholding and Withdrawing Life-prolonging Treatment: Good practice in Decision-making (2002) 11

Question 9

Treatment futility

Answer 9

Effect (physiological) vs benefit (normative)

• Treatment which was either useless or ineffective
• That which fails to offer a minimum quality of life or a modicum of medical benefit
• Treatment that cannot possibly achieve the patient’s goals
• Treatment which does not offer a reasonable chance of survival

Question 10

Futility

Answer 10

“A treatment which cannot provide a minimum likelihood of quality of benefit should be regarded as futile and is not owed to the patient as a matter of moral duty’?

Question 11

Doctrine of Double Effect

Answer 11

“Nothing hinders one act from having two effects, only one of which is intended, while the other is beside the intention. …Accordingly, the act of self-defence may have two effects: one, the saving of one’s life; the other, the slaying of the aggressor.” Thomas Aquinas

Double effect provides a framework that permits tolerance of the lesser of two evils in the following circumstances:
• The nature of the act itself is itself food, or at least morally neutral
• The agent intends the good effect only
• The agent does not intend the bad effect either as a means to the good or as an end in itself
• The good effect outweighs the bad effect in circumstances sufficiently grave to justify risking or causing the bad effect and the agent exercises due diligence to avoid or minimise the harm

R v Adams[1957] •Devlin(trial judge) Direction: “If the first purpose of medicine, the restoration of health, cannot longer be achieved there is still much for a doctor to do, and he is entitled to do all that is proper and necessary to relieve pain and suffering, even if the measures he takes may incidentally shorten life.” 


R v Cox [1992] “There can be no doubt that the use of drugs to reduce pain and suffering will often be fully justified notwithstanding that it will, in fact, hasten the moment of death. What can never be lawful is the use of drugs with a primary purpose of hastening the moment of death” 

• Endorsed by the Law Lords (e.g. Bland [1993])
• Applies to drugs intended to relieve pain, suffering and distress (Lindsell [1997])
• Tends to refer to morphine and diamorphine
• Referred to in GP training literature: e.g. Gillies JCM (2009), Ethics in primary care: theory and practice, InnocAiT, 2(3):183-190
• Still hotly debated topic – RCGP 2010 conference!

Question 12

Problems with the ethical/legal double effect

Answer 12

Problem 1: uninformed

• Double effect is overstated
• Painkillers kill pain (not patients!)

Problem 2: unclear

• Double effect has unclear legal status
• No intention to kill, no killing, or justified killing?

Problem 3: unfair
- Double effect is only selectively applied
Problem 4: dangerous?
- Focus on killing pain risks overlooking killing patients

Question 13

Doctrine of double effect in practice

Answer 13

From the Association of Palliative Medicine position statement on DDE

1. There is a misconception that morphine related drugs and sedative drugs bring about death more quickly and that doctors both know this and in some way condone their use with the double effect.
2. The APM refutes this claim: it knows of no credible research evidence to suggest that a patient’s life is shortened either by opioids or sedatives when used in line with accepted palliative care practice
3. The APM believes that DE is unnecessary to justify the use or dosing regimes necessary to manage pain or distress in all but the most exceptional circumstances. 


Question 14

Euthanasia

Answer 14

• Suicide
• Assisted suicide
• Physician assisted suicide
• Passive euthanasia
• Voluntary euthanasia
• Non voluntary euthanasia
• Involuntary euthanasia

Argument for all that they are in the dying person’s interests.

Question 15

Euthanasia - pros

Answer 15

• Suicide is allowed, and it is unfair that people who cannot kill themselves cannot choose this 

• If people can refuse treatment and die slowly/painfully, should there not be a kinder option? 

• If you know a painkiller will shorten life, you intend to shorten life and should stop pretending 

• People’s autonomous choices should be respected, and they should be helped to die if they so wish 

• Sometimes living is worse than dying, so death is preferable and should be assisted

Question 16

Euthanasia - cons

Answer 16

• Suffering can be prevented/treated without killing people 

• Pressure on old, sick and disabled to die, perceived duty to die 

• Slippery-slope – logical ski and empirical ski
• Medicine is about extending life and reducing 
suffering but not killing 

• Doctors will lose trust if they start killing people

Question 17

Cardiopulmonary death

Answer 17

Thus it became possible for a person with severe brain damage/brain death to have a cardiopulmonary system that could still support their organs/body 


Are they alive or dead? 


Technology created a gap between cardiopulmonary death and neurological death where previously there was none:

• Cardiac bypass machines
• Patients on ventricular assist devices
• Polio sufferers with respiratory muscle involvement

Question 18

Harvard Brain Death Committee 1968

Answer 18

• A patient dies when they enter an ‘Irreversible Coma’ with no evidence of CNS activity 

• This was then clarified into the Whole Brain Death standard
• The whole of the person’s brain has ceased to function permanently 

• This is the neurological standard used in the majority of countries

Question 19

Problems for whole brain death

Answer 19

The challenge for this view is how to classify human beings that never had a brain structure in this manner, for example very early stage foetuses. 


Alternatively clinical experience has shown that whole brain dead patients can be kept ‘alive’ until their foetuses have finished gestating. 


Question 20

Brain Stem Death

Answer 20

Two neurosurgeons from Minnesota developed the Brain Stem definition just after the Harvard Committee published their report 


The death of the brain stem alone is enough for a person to be ‘dead’ 


This is the standard used in the UK

Question 21

an artificial brain stem

Answer 21

It seems counterintuitive that the entire metaphysical nature of death should change on the intervention of a machine.

Question 22

SEP: higher brain death

Answer 22

• ‘human death is the irreversible cessation of the capacity for consciousness’
• For humans, the irreversible loss of the capacity for consciousness entails (is sufficient for) the loss of what is essential to their existence;
• For humans, loss of what is essential to their existence is (is necessary and sufficient for) death;
• Therefore, for humans, irreversible loss of the capacity for consciousness entails (is sufficient for) death.

Question 23

Higher brain death objections

Answer 23

• One objection to this view is in its conclusions that patients who enter a persistent vegetative state have died. 

• This is counter to the very strong intuition that the warm, respiring, pulsatile bodies of these patients are alive in an important sense. 

• Would society put in place all the legal safeguards post Bland if we genuinely believed these patients were dead?
• A second problem arises with anencephalic infants. 

• If you never have a higher brain, can you live?

Question 24

Death is not a moral concept

Answer 24

Singer argues that the questions have become conflated:

1) When does a human being die? 

2) When is it permissible to remove organs such as the heart from a human being for the purpose of transplantation to another human being? 
The definition of death is being asked to do moral work – however it is a metaphysical concept. 


Does death harm the one who dies?
Epicurus thinks we shouldn’t…

Question 25

Should we fear our own death?

Answer 25

1. The harm thesis
2. Epicurus
   a. Letter to menoeceus
   b. Challenges locating the harm
3. The nature of harms
   a. Deprivation as a harm?
4. Comparativism
5. The timing problem
6. The Cambridge change

Question 26

The Harm Thesis

Answer 26

this is the claim that death can harm the individual who dies

Question 27

Epicurus (341-270 BCE)

Answer 27

Epicurus was an ancient Greek philosopher as well as the founder of the school of philosophy called Epicureanism. 


For Epicurus, the purpose of philosophy was to attain the happy, tranquil life, characterized by ataraxia—peace and freedom from fear—and aponia—the absence of pain—and by living a self-sufficient life surrounded by friends.

He was a positive hedonist and taught that experienced pleasure and pain are the only measures of what is good and evil; 


‘Death, therefore, the most awful of evils, is nothing to us, seeing that, when we are, death is not come, and, when death is come, we are not. It is nothing, then, either to the living or to the dead, for with the living it is not and the dead exist no longer.’ 


Epicurus in a letter to Menoeceus

Question 28

The problem of timing of the harm

Answer 28

• Epicurus - base of his argument: 

• The classic view of a harm is that it must be experienced to be harmful and thus has:
o A subject
o A time that it occurred
• Eg stubbing one’s toe 

• The subject is clear when one is alive, but more difficult if one accepts the premise assumption that there is nothing after death 

• The timing is also difficult. Either death harms us whilst we are alive, or harms us in some way after we die 


Further premises:
• A person cannot be causally affected by a future event 

• What occurs before I exist might well affect me but only 
whilst I exist 

• Events can only effect someone by having a causal impact on them 

• Philosophers rarely agree on anything but this is something most are very keen to defend! 


Question 29

Nagel on death and the nature of its harms

Answer 29

• Nagel points out that clearly if it is to harm us it is through those things that it deprives us of.
• He expands this to say that simple organic survival does not form part of this – arguing that all other things being equal there is little to choose between instant death and a coma for 20 years and then death

Question 30

Deprivation as a harm

Answer 30

• Imagine the following scenario: 

• Your friend is given her ticket and your ticket for the 
party of a lifetime. 

• She then decides not to invite you, even though you would have very much enjoyed that party. You are never aware that there was an invite for you too. 

• It seems intuitive to say that you are worse off because you were not able to go to the party and your so- called friend caused this harm through a deprivation 

• Nagel describes this as the ‘what you don’t know can’t hurt you’ argument 

• He argues that if this holds then the follow is true: 

• Imagine a man who is betrayed by his friends, ridiculed behind his back, and despised by people who treat him politely to his face – none of this can be said to be a misfortune so long as he remains unaware and does not directly suffer as a result.

Question 31

Comparativism

Answer 31

• Imagine two worlds:
o Where S dies at time T
o Where S survives

• Compare the total amount of welfare for S across the two worlds, and the better world is the one with more
• This will usually be (b), hence S’ death harms S
• The deprivation of the goods S would have experienced is the harm visited when she dies in world A

Question 32

Comparativism vs Epicurus

Answer 32

• A key feature of the comparativist approach is the idea of a deprivation as a special kind of harm that is both implicit in a very wide range of ordinary, confident evaluative judgments.
• This is not easily reconcilable to the ‘Epicurean’ perspective on which only bad experiences can be thought of as harms.

Question 33

What are the three major definitions in welfare?

Answer 33

Preferentialism
Pluralism
Comparativism

Question 34

Positive Hedonism

Answer 34

S’s experience of pleasure at time T is the only thing that is intrinsically good for S at time T. Pain is the only intrinsically bad event. The more pleasure at time T, the better the event.

Question 35

Preferentialism

Answer 35

Welfare is improved when desires are fulfilled. S’s welfare increases at T if at T, S desires P and P holds. For example, wanting to be a well thought of writer

Question 36

Pluralism

Answer 36

A more general combination of the two

Question 37

Comparativism

Answer 37

works for all three, even if each of the three has its own problems

Question 38

subsequentialism

Answer 38

that the harm occurs subsequent to the death appears to have the difficulty of lacking a subject, as for events that occur after our death, we ourselves are no longer existent.

Question 39

indefinitism

Answer 39

is the position that the timing of the harm is difficult to determine, but that it exists, such as the timing of the harm of going bald.

This allows the indefinitist approach to be held, but as Luper points out, does not give us the answer, it just suggests that there is one.

Question 40

Concurrentism

Answer 40

the idea that death harms us during the dying process

there is clear subject and clear harms being experienced

it does however have the same problem as subsequentialism which it comes to post-mortem harms, as in the stage of death there is no subject

however, if death is the moment after life ends, again there is the problem of lacking a subject

Question 41

eternalism

Answer 41

the harm that is caused at all points in time, something is always bad for you - but think of a stubbed toe?

Question 42

Priorism

Answer 42

argues that some harms can exist prior to an event. Luper’s example is of the having an interest to complete a treasured project . 


If I die before the project is complete, then ‘I will never complete my project’ is true, and it is true at all the points where I hold the interest in completing the project and my death harms this interest, even before it happens. 


This only applies for preference satisfaction version of welfare but could be a realistic option

Epicurus would disagree obviously

Question 43

cough syrup

Answer 43

If there was a simple solution people wouldn’t be proclaiming all these variations

One argument for the comparativist here will involve the attempt to show that the timing problem is implicit in the general idea of deprivation is harm…

Therefore it is not something that is contributed by the claim that death is a deprivation harm

Question 44

The Cambridge Change

Answer 44

Geoffrey Scarre takes the argument another way… 


He argues that people can not undergo intrinsic changes in welfare after their deaths but can undergo relational changes (Cambridge changes). 


Eg. Non-brother to brother 


These changes can be undergone even after death e.g. 
tallest person in history 


if this was the person’s life ambition to be remembered as this and then someone taller was born this could be argued to be a harm to them (preference satisfaction welfare) 


No subject needed as no intrinsic properties changed and time point is easily identifiable. 


Question 45

Summary of end of life ethics

Answer 45

Epicurus argues that death is not to be feared as although dying might be (briefly) unpleasant you don’t exist at the time you are dead and so nothing can harm you 


He poses that challenges of:

• Lack of subject 

• Lack of time 


Many different philosophers have tried to argue against this – 
but all appeal to more removed intuitions 


Should you fear your own death? (As opposed to the dying process)