MEDICAL ETHICS ANTHOLOGY Flashcards
Model answer: Good or bad medical practice
The first point to be clarified in this passage is the BMA statement that there is a difference between actively terminating life and treating a patient in a manner that in the end may result in death. By this the BMA is distinguishing between a practitioner deliberately acting to terminate a life for instance giving a lethal injection or concoction that will knowingly and wilfully kill a patient and acting in a way that causes death but wasn’t intended to. The latter might for instance occur when a doctor gives a patient a medication knowing there is a risk in giving it, but also knowing that there are no other options that might assist them in their suffering. The first of these two clearly refers to assisted suicide or euthanasia.
A second point for clarification is the emphasis on the duty of the doctor to ensure a patient dies with dignity and as little suffering as possible. This reflects the duty of care that practitioners are bound to in the hippocratic oath. The work of the doctor is to heal and provide palliative care that reduces suffering and maintains a patient’s dignity. Many would argue that this excludes a doctor’s involvement in actively terminating life either through abortion or euthanasia, although others believe this can be seen to support actively assisting dying if it allows for a dignified death and an end to persistent and unwanted suffering.
This second point is, however, further clarified by the third point, ‘where drugs are given or other procedures, even at the request of the patient, should remain illegal.’ The BMA makes it very clear that in the United Kingdom doctors may not involve themselves in any voluntary act of euthanasia acting on the wishes of the patient. To do so is illegal and is tantamount to manslaughter or murder. The only times a doctor may act to knowingly end a patient’s life is through non-voluntary euthanasia, when the patient is on life support and the decision is made that keeping them alive is not in their best interests or that of the family. Whilst other countries now allow voluntary euthanasia, the United Kingdom continues to maintain that wilfully assisting a person to die at their request is not legal, ethical or in any way part of a doctor’s role.
Good or bad medical practice?
A ‘third party’ in law refers to any agent other than the principal agent and in the case of euthanasia this would generally mean a doctor (sometimes also referred to as the ‘physician’)……Whilst the moral basis for sustaining life and allowing death is in transition, the medical profession and legislators will continue to inspire strong reactions.
Ronald Dworkin on the Sanctity of Life and Euthanasia
Unlike Singer, Dworkin suggests = secular, non-religious understanding of the concept of the sanctity of life,
–> human beings are regarded as the highest product of evolution, so that human life can be seen as intrinsically important even from this perspective.
–> For Dworkin, those on both sides of the euthanasia debate have tended to lose sight of the common ground that exists between them on this point.
For him, the issue = not whether the principle of the sanctity of life should yield to some other value, like humanity or compassion, but how life’s sanctity should be understood and respected.
He writes that ‘making someone die in a way that others approve, but he believes a horrifying contradiction of his life, is a devastating, odious form of tyranny.’
On the other hand, for others, ‘the struggle to stay alive, no matter how hopeless or how thin the life, expresses a virtue central to their lives, the virtue of defiance in the face of inevitable death.’
Dworkin thinks = laws we make about euthanasia should reflect the patient’s right to self-determination as an expression of the sanctity of their own individual existence, when it comes to deciding how their life should end.
–> the law should be flexible enough to allow them to end their lives with dignity if they wish, whilst allowing others to fight on until the end if that is what they want to do.
–> State should ‘encourage people to make provision for their future care themselves’. By this Dworkin means that the government should prompt people to make it known what their wishes would be should they, for example, become terminally ill or involved in an accident which renders them brain dead.
–> In cases where no prior wish has been expressed, he thinks ‘the law should so far as possible leave decisions in the hands of their relatives or other people close to them, whose sense of their own best interests…is likely to be much sounder than some universal, theoretical, abstract judgement born in the stony walls where interest groups manoeuvre and political deals are done.’
Three Moral Principles
Three principles presuppose that the doctor is working from the traditional SOL position enshrined in the part of the Hippocratic Oath which states ‘I will give no deadly medicines to anyone if asked, nor suggest any such counsel’ (BMA Handbook, p.69).….. Morally if they engage in treatment and then decide to withdraw treatment on the grounds that the baby will no longer have a worthwhile life, it may no longer be considered indirect killing but an act of active non-voluntary euthanasia or murder (See Singer, Rethinking Life and Death, 1994, pp.75-80 for examples and discussion.)
Peter Singer argues against the distinction between active and passive euthanasia.
As both types of euthanasia typically result in the death of the person, he notes that the consequences are the same.
But when treatment is withheld, as in passive euthanasia (e.g. by not administering a course of antibiotics that might keep a patient with dementia alive), a lingering, painful death often results, while ‘nature takes its course.’
Singer therefore believes that active euthanasia is more humane.
1) If A chooses to shoot B we classify this as an intended act; if C sees A and fails to stop A killing B, then this is intended omission
2) we would say that C is also responsible for not acting but in medical ethics in certain circumstances omission can be sees as acceptable e.g. if a baby is born prematurely and will die, the doctor might decide to ‘let nature take its course’ and withhold life-sustaining treatment but this only happens in exreme cases
DOUBLE EFFECT: Another indirect argument has a long tradition in Natural Law ethics and involves two kinds of intention…..However, the term ‘euthanasia’ is resisted in the same way that ‘abortion’ is avoided for similar reasons. But is the DDE open to abuse?
• Is there a satisfactory distinction between intending and foreseeing? Might one say that the DDE is bad medicine, that if I foresee death but fail to act, then this is an omission which is a form of indirect euthanasia – which is rejected by the SOL?
1) it is acceptable to perform a morally good actions which results in bad side-effect as long as that was not intended
2) this is often used to justify use of high amounts of pain-relieving drugs to relieve suffering even though the doctor knows the side effect are of hastening the patient’s death
BUT- intentions cannot be tested and the distnctions between intentions and foresight could be enough to justify certain types of passive euthanasia, the doctor should arguable always know the effects of medicine he is administering
- According to Aquinas’s principle of double-effect, an action may be permitted if:
1) the action is moral
2) the person doing it intends the main effect of the action to be good rather than bad
3) there is another, unavoidably bad effect which also results from the same action. - In cases of abortion, the principle of double effect might justify a Catholic doctor who is morally opposed to abortion performing an operation on a pregnant woman who will die if her cancerous womb is not removed or her ectopic pregnancy is not terminated. As long as the doctor intends to save the mother’s life and there is no other way to do so apart from having the operation the secondary effect (abortion) is allowable in these circumstances.
- However, our intentions are hidden from others and so this principle makes it possible for us to conceal what might be our malicious intentions from others.
- This may be particularly significant if the principle of double effect comes into play where euthanasia is concerned. For example, a doctor who wishes to prevent pain in a dying patient may give that patient a drug which the doctor knows will shorten the patient’s life. As long as the Doctor’s main intention is to relieve pain, the secondary effect (eventual euthanasia) is allowable.
More on the principle of double-effect
- Natural Law (as formulated by Aquinas) deals in moral absolutes – primary precepts that cannot be broken regardless of the situation.
- One of the primary precepts is to ‘protect and preserve the innocent’. It is therefore a secondary precept and an absolute moral rule that you should never kill an innocent person. It would seem that euthanasia is always wrong.
- However, we mustn’t forget the principle of double effect (which was formulated by Aquinas and was, in turn, adopted by Roman Catholic theology). It is wrong to kill, but is it wrong to give someone pain relief if a secondary effect is that they die?
- So while Natural Law clearly does not support active euthanasia, it may well allow an action whose intention is merely to relieve pain, even if the action leads to death.
- However, Peter Singer has criticised the reasoning behind the principle of double effect.
- He argues that if we foresee both effects then we must take responsibility for both of them.
- And he also argues that if we think that a person’s future quality of life may be so poor as to warrant relieving their suffering through an overdose of a painkiller then our decision is not really one based on the teaching of the sanctity of life. It is actually a utilitarian one based on what we think would be the consequences if we allowed the person to go on living in a state of unbearable suffering.
- In other words, when someone makes use of the principle of double-effect to justify their actions, they are actually behaving like a utilitarian in disguise.
- The principle is also based on intention or motive that is hidden. So there is no way of telling whether a doctor giving pain relief is doing so for the right reason.
Ordinary and extraordinary means.
The principle of ordinary and extraordinary means is used both by weak SOL (WSOL) arguments and QOL proponents…..For instance, if a doctor withholds life-sustaining treatment, against his or her better judgement, but through respect for patient autonomy, the result might be condemned either as an act of professional negligence or wilful killing.
WSOL = Weak Sanctity of Life QOL = Quality of Life
- Supporters of a weak sanctity of life stance realise that the advances of medical science have meant that the boundaries between life and death are far more flexible than previously thought and so would allow exceptions to the general sanctity of life position.
- If it is not clear what constitutes independent ‘life’ or when independent life begins then there may be certain situations in which abortion is morally justified. Christian proponents of a weak sanctity of life stance tend to balance the Bible’s pro-life teachings with Jesus’ emphasis on love and compassion as a justification for abortion in certain cases.
- In some cases, Christians might regard withholding treatment (passive euthanasia) and letting nature take its course to be morally acceptable, with the result that the patient dies. As no medical intervention takes place, the doctors and medical staff would not be ‘playing God’. For example, in Catholic teaching, using extraordinary measures to keep a patient alive is thought of as unnecessary, though there is some debate about where the lines should be drawn in this respect e.g. whether the use of a respirator represents an extraordinary treatment.
- In 2004, Pope John Paul II stated firmly that a feeding tube must not be withdrawn from patients in a vegetative state, saying that ‘the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act.’
- However, it is hard to see how the use of a feeding tube is not a medical act, given that inserting one is not something that people without medical training can do.
ORDINARY AND EXTRAORDINARY MEANS
1) concerns the lengths the doctor is obliged to go to when preserving life- what counts as proportionate
2) BMA allows competent patients to refuse treatment even one which could prolong life which result in nature taking its course
3) this denies the doctor the autonomy to save the patient- this could be seen as passive euthanasia
4) a very disabled baby might be considered so ill that no amount of surgery would improve their conditions and so the doctor could prescribe nursing care only as proportionate treatment to their needs, knowing the baby will die
5) Finnis’ basic goods provide a list of what is valuable in life e.g. aesthetic experience, social ability etc
Law and Morality
So far the discussion has centred on the doctor-patient relationship within the constraints of law.…The BMA cites (Medical Ethics Today, p.153) the situation in the Netherlands where some 1000 (or 0.8 per cent) of all deaths a year are the result of non-voluntary euthanasia.
The figures for non-voluntary euthanasia in the Netherlands are not very reliable.
First of all, non-voluntary euthanasia is illegal in the Netherlands, making evidence for its occurrence difficult to collect and substantiate.
Secondly, the figures include the withdrawing of treatment from very premature or damaged new-born babies.
Thirdly, the safeguards in the Netherlands euthanasia act are not as strict as those contained, for example, in the Death with Dignity act in the state of Oregon in the USA, where euthanasia is also legal.
Stricter legislation could therefore, in theory, be drafted, that could serve to block any descent down a slippery slope e.g. it could specify precisely which conditions euthanasia might be permitted for.
Finally, in her examination of the evidence supporting the claim that the Netherlands has already started its descent, Dr Penney Lewis has argued that there is none.
There is nothing to back up the claim that non-voluntary euthanasia has increased because of the legalization of the voluntary, nor is there evidence from Oregon or Belgium.
The SOL deontological response is to point to a number of recent liberalisations in the law which illustrate the wedge taking effect. For instance, abortion in the UK is illegal but is permitted in extreme cases. Since 1967 (when the Abortion Act was introduced in England and Wales), the large number of abortions for 16–24-yearolds suggests that ‘exceptions’ (e.g. threat to psychological life of the mother) are effectively being used as a form of birth control. Many people now think that abortion is legal and in practice an abortion is usually given on demand. Another example might be the liberalising of the divorce laws and the decline of the family.
Mary Warnock argues against the analogy with abortion.
As she puts it, ‘…this analogy is by no means exact, if only because before 1967 abortion was already widely and increasingly carried out by ‘back street’ practitioners, who caused many deaths.
Indeed, part of the purpose of the new law was to bring this to an end by ensuring that abortions were performed only competently, and by those licensed to do so.
There is a difference between attempting to control by regulation a practice that is widespread, increasingly in demand and dangerous, and attempting to permit a practice that that will arguably never be widely in demand.
We hold that the case against euthanasia must be defended separately, and not built on a doubtful analogy.’
Case for legalising euthanasia
1) personal autonomy:
- in 1961 the Suicide Act decriminalised suicide which created disparity between those who have the means to end their lives and those who don’t
BUT- third party involvement shifts the responsibility to a doctor to end the life which makes the situation more like euthanasia and could easily be exploited. This is hard for the doctor as well as for family and friends
Quality of LIFE
1) In Netherlands there are stipulations e.g. the request to die must be explicit ad persistent and without coercion and the patient must be facing unbearable pain with not room for improvement and two doctors must approve. This is a model which prevents the slippery slope and cares for society’s needs
objections to legalising euthanasia- the thin wedge argument
1) ignores sanctity of life
2) the thin end of he wedge argument:
- ‘permitted as an exception becomes the rule’
- there are always those exploit the rule and what begins with best intentions results in undesirable ends
3) Nazi killing of innocent people
BUT- relies on an inductive claim that because things have gone badly in the past they will go badly in the future- this is unwarranted logically especially with so little evidence of abuse of euthanasia
BUT- Helga Kuhse- Nazi killing of innocent people had basis in racial prejudice and
objections to legalising euthanasia- patient autonomy
1) euthanasia would cause widespread damage to the relationships between doctor and patients and destroy trust- maintaining the autonomy and liberty of all people is more morally important than the case-by-case issues of pain and discomfort that terminally ill people face
2) a change in law might bring about a change in social attitudes to illness and disability
responsibilities of a fair society
1) Mill- outlines the function of law both to exist as a moral guidance and to in turn protect the right of individuals so that the minority doesn’t have too much sway over the majority and the majority doesn’t dismiss the minorities
2) legalising euthanasia threatens the autonomy of those most vulnerable in society
3) Bernard Williams- precedent effect- legalising something may be seen as a tacit approval
personal autonomy and right to die analysis
1) people have the right to die and some people have rational reasons to commit suicide
2) BMA believes that person is within their rights to refuse surgery on the grounds that it is over and aove what is needed ordinarily for bare existence- what is the difference between letting nature take its course and personal willing to die by refusing treatment
3) Glover- voluntary euthanasia is justified in those cases where we know that the person would commit suicide if they could. We must:
- understand why a person wants to die
- individual must be persistent
- consider when it would be right to assist suicide
BUT- no one is ever in their right mind to decide that they want die, someone who is suffering might not be seeing the possible improvements of medicine
BUT- this ignores familial rights- family wish to spend time with the person and may know them well enough to determine that they are not in their right mind to decide on their death
