Biomedical Ethics
Definition of Euthanasia:
Narrow: The intentional ending of a persons life either out of motives of mercy, beneficence, or
respect for personal autonomy; mercy killing.
Broad: The act of either intentionally ending a persons life (active) or of permitting a person to
die (passive).
Definition: The cessation of the essential characteristics and capacities that are necessary and
sufficient conditions in order for a person to be alive.
Determination of death: What are “necessary and sufficient conditions” in order for a person to
be alive?
- Sufficient: Condition P will cause event Q but it is not necessary for Q. “if… then…”
- Necessary: condition P must be in place in order for event Q to occur. “only if… then…”
- Sufficient and necessary:
Death:::
Criteria for determining death:
- Failure of heart and lungs: the traditional determining factor for death has focused on
the heart and lungs. When the breathing of air and the flow of blood have arreversibly
stopped circulating, death has occurred.
- Separation of body and soul: Aristotle belived that the animating principle of life was
the soul. Christianity takes a similar view and therefore it is when the sould leaves the
body that death occurs.
- Brain death: the absence and complete irrecoverability of all spontaneous brain activity
and all spontaneous respiratory functions. This is often referred to as whole brain death:
the death is considered to have occurred when the entire brain has died.
WBD (whole brain death) is a sufficient condition, but is it a necessary condition to
declare someone dead?
- Neocortical Death: According to this criteria, a person is determined as dead when the
outer layer of the brin covering the cerebrum, the neocortex, has irreversibly ceased to
function. This is often referred to as partial brain death.
IMPORTANT DISTINCTIONS:
Active/passive
Active euthanasia: the intentional and direct killing of another human life either out of
motives of mercy, beneficence, or, respect for personal autonomy; mercy killing.
Passive Euthanasia: the with holding or withdrawing of a life-sustaining treatment when
certain justifiable conditions obtain and the patient is allowed to die.
Witholding treatment: treatment in a patient is never begun
Withdrawing treatment: stopping treatment that has already begun
While there may be an emotional difference between these two actions there is really
no morally relevant difference between them.
Voluntary: When a competent, informed patient autonomously requests it; ie. Either presently
conscious or through an advanced directive like a living will.
Non-voluntary: Occurs whenever a person is incapable of forming a judgemtn concerning
euthanasia and has no advancement directive.
Involuntary euthanasia: Occurs when a person expresses a desire to live but is killed or allowed
to die.
Ordinary means: all medicines, treatment, and preocedures that offer a reasonable hope of
benefit without places undue burdens on a patient (e.g. pain or other serioud inconvenience).
Exrtaordinary means: those medicines, treatments , that are not ordinary, ie. They involve
excessive burdens on the patient and do not offer reasonable hopes of benefit.
The use of “ordinary/extraordinary care”: is slowly being replaced with a burden/benefit
assessment. In each situation an assessment is made as to the benefits to the patient in light of
the burdens he/she is likely to incur from the treatment.
1. April 14th 1975: Karen Ann Quinlan (age 21) slips into a coma after mixing drugs and
alcohol; placed on a respirator and naso-gastric tube; will later be diagnosed as PVS
2. July 31, 1975 parents signed a release to remove Karen from respirater.
3. The hospital refused to remove her and the case wetn to the superior court of NJ where,
on November 10, 1975, Judge Robert Muir ruled that she could not be removed because
a. her wishes were unsubstantiated, b. she was not brain dead, and c. there is no
constitutional right to die.
4. The case was appealed to NJ state supreme court
5. I Jan 1976, patient’s have right to decline treatment and this right can extend to the
family and patient’s guardian if patient is incompetent and physicians conclude there is
“no reasonable probability: of return to a cognitive sapient state.
10/31
1990: Nancy Cruzan:
Jan 11, 1983: 24 year old is involved in a car accident and ceases breathing. Due to
anoxia, she is declared to be PVS; she is connected to feeding tube but can breath on her
own.
After 5 years, parents request removal of tube, saying Nancy would’ve wanted this but
hospital refuses
July 27, 1988 Jasper County court grants requests; appealed to Missouri state supreme
court.
1988 MSSC reverses lower court ruling stating that state has a compelling interest in
preserving life, regardless of quality of life, unless clear and convincing evidence of the
patients’s wishes concerning the end of life sustaining treatment was available. Nancy
left no advanced directives
July 25, 1990: Applealed to Us supreme court which upheld the MSSC ruling citin that
(a): states can determine what constitus clear and convincing eve=idance and withdrawl
of nutrition and hydration is no different from withdrawing other medical treatments.
Terry Schiavo: On Feb 25, 1990, 26 year old Terri suffers a cardiac arrest which leads to brain
damage due to lack of oxygen; is to put on a feeding tube.
June 18th 1990 the court appoints her husband, Michael Schiavo as her legal guardian
Wins two lawsuits in 1992
On Feb 14th 1993, Michael has a falling out with Terri’s parents (Bob and Mary Schindler)
1998 Michael petitions court to remove Terri’s feeding tube
Over the next 7 years a legal battle ensues between Michael and the schindlers about
her condition, her wishes, and who has the authority to speak for her
During this time, she was weaned off the PEG tube on three separate occasions
The case was exacerbated On march 18th, 2005 the peg tueb was removed for a third
and final time and she died on Mrch 31st.
And autopsy determined that her entire cerebal cortext had turned to liquid
Args in favor of active euth
Respect for autonomy argument: Persons should have the right to self-determiantion
concerning al aspects of their lives, including the mannor and time of their death. This I
soften called the right to die argument.
oObjection #1 this view of autonomy is too strong, too individualistic and too
independent.
oObjection #2: a coherency problem: can one coherently have a natural right to
die? All natural rights presuppose our self interested attachement to our own
lives. For one to argue that one has a right to die is to argue that one has the
right to annihilate the very basus of all rights including the right to die.
oObjection #3 IN THE CONTEXT OF EUTHANASIA, this form of autonomy is always
coupled with suffering. However, if the argument from autonomy is valid, then it
should be able to stand on its own. Any autonomous individual at any time has
the right to die and has the right to ask others to help- but no one ever argues
this.
oObjection #4: as Christians we recognize that the life we are asking to end is not
your life. It is a gift from God, given to us only on load, which we live in
stewardship to Him.
Mercy arg: When possible, we ought to relive the pain and suffering of another person
and sometimes this obligation will require mercy killing.
oObjection #1: ignore other morally preferable ways to handle pain and suffering.
While these methods may not be ideal, they may be morally preferable. The fact
that you are in pain does not justify doing anything to end pain.
oObjection #2: this arg communicates the wrong message about pain and
suffering. Suffering is a natural part of the human experience. It is part of life, a
means of growth, and it shouldn’t necessarily be avoided at all costs. We should
relive suffering when we can but recognize there is a limit to when we can.
oObjection #3: for Christians suffering has an even deeper meaning. We worship a
suffering savior. God understands our suffering and pain as he has lived through
it himself in the person of Jesus Christ. In our suffering we identify with Christ.
oObjection #4: this is always coupled with autonomy, but if valid it should stand on
its own. What about those suffering but are not autonomous? Can we kill them
non-voluntarily or involuntarily? Must we let them suffer?
The bare difference argument: An attempt to erase the distinction between active and
passive euthanasia by showing they both result in the same end and therefore they are
ultimately the same thing. Ill: the boy in the bathtub.
Objection: this presents an indadequate analysis of moral actions. Moral acts are more
than just the movement of boyd parts. Moral acts have to take into account motive and
intention as well as the means to an action. Of the three, intension is where the real
essence of the moral act lies. This illustration differs only in means to an end (killing vs.
allowing to die)
In active euthanasia the intention is the death of the patient. In passive euthanasia the
intention is the relief of the patient from excessive burdens with the knowledge that this
will most probably, through not necessarily, result in the patients death, In that sense
the illustration is highly disanalogous.
Second half: Arguments in favor of passive Euthanasia:
Passive euthanasia recognixes that medical science can only do so much, and that one
must recognize this and allow death to come at the proper time. A time comes when we
need to stop “struggling against death: by any means possible.
There is a distinction between passive and active euthanasia. There is a difference
between allowing someone to die and hastening death. Zin passive euthanasia death is
not intended and the action is not the cause of death, the debilitation is.
Passive euthanasia may be justifiable under certain circumstances. Five criteria for
passive euthanasia:
1. The patient is terminal
2. Death is imminent: very soon, hours or couple of days at most.
3. Treatment is extraordinary: excessively burdensome with little benefit.
4. Death is not directly intended and the action taken is not the direct cause of death.
5. The patient has autonomously requested or agreed to the action. This last criteria may
be overlooked in some cases.
Active euthanasia violates a negative right to “do no harm” while passiv d euthanasia
violates only a positive right to “receive the benefit of treatment”
A mistaken diagnosis can be reversed in passive euthanasia: the person could get well
from the disease and this would be welcomed.
Active euthanasia violates the principle of the duty of physicians to preserve life while
passive euthanasia recognizes the limits of that duty.
Active euthanasia weakends respect for human life, while passive euthanasia respects
human life and its limits.
The intentional killing of human life for no just cause is simply wrong. Human life has
intrinsic value itself. Passive euthanasia does not violate this principle.
Four issues related to euthanasia:
Foregoing nutrition and hydration:
Should the administering of artificaly induced fod and water be handled in the
same way as other medical treatments in the consideration of passive
euthanasia? Can they be withdrawn from a terminally ill…
Food and water are in a different category from medical procedure. Medical
treatment is performed for therapeutic reasons to treat some diseas. Food and
water do not have as their purpose the treatment of disease, but they are fo
the sustaining of life.
In passive euthanasia< it is the disease which is the direct cause of death, not
the action taken by the health care worker.
In withdrawing or withholding extraordinary life-sustaining treatment (passive
euthanasia) the focus is on the quality of the treatment. However, in
withdrawing OR WITHHOLDING FOOD AND WATER (active euthanasia) the
focus shifts from the quality of treatment to the quality of patient’s life itself.
Arguments for removal:
-1990 crusxan decision: supreme court ruled that the withholding of artificial nutrition
and hydration is no different than removal od other life sustaining treatments in the
context of end of life care.
oIf the person is going to die in a very sort tmime, whether or not he had
nutrition and hydration or it is medically determenined that the patient cannot
absorb nutrients.
oSo death is not intended nor directly caused by the forgoing of nutrition or
hydration.
oThe means of administering food and water was excessively burdensome and
extraordinary
oIf the patient has left an advance directive concerning her desires should she
end up in this situation.
PVS
-Persistent vegetative state (PVS): a condition of permanent unconscious in which the
person is completely unaware of himself or his surroundings though he may appear to
be awake and go through regular sleep wake cycles.
-Usually the result of permanent neocortical impairment and is considered irreversible.
-PVS patients may exhibit many lower-brain stem function, but have no higher brain
functions.
-All capacity for consciousness, self-awareness, memory, personality, communication, and
sentience are irreversibly lost.
-Is removal of nutrition and hydration justifiable?
-These persons are not biologically dead. The heart and lungs are functioning normally
and breain death has not occurred. They are still living human beings containing the
image of God.
-There are cases, though rare, of patients diagnosed with PVS h=who have spontaneously
recovered, some as long as 6 months.
-Food and water are not extraordinary care, but ordinary care for these patients.
Arguments to justify it:
oThese beings cant really ne considered “persons”. They have lost the complete
basic inherent capacity to function as a person
oRecent breakthroughs have been made which habe made the determination of
neocortical irreversibility virtually certain.
oIf er do not recognize neocortical death as the death of the person, then e will be
forced to keep thousands of bodies alive for several years with no hope of
functioning as persons. The longest case of PVS is 37 years.
Advanced directives:
oAn advanced directive is a set of instructions from a competent, autonomous,
informed person regarding decisions about future medical treatment in the event
that the person becomes incapable of making a decision at a future time.
Living wills: a document that expresses an individuals preferences for
treatment. Recent studies have indicated that living wills are not an
effective means of advanced directives.
Durable power of attorney: a person, designated in advance by the
patient, to act as a proxy decision-maker at the time that the patient is no
longer able to make decisions concerning his own welfare.
Living wills aren’t really effective, heres why:
oFew people actually complete them
oTreatment preferences are not clarly states or comprehended
oLW often do not get transmitted to those making medical decisions
oLW may have little effect on surrogate decision making, and little impact for
incompetent patients
oConceptual problem: informed consent; prior wishes/present welfare
12/5/23
Three different types of deception: lying:
Broad definition: verbalizing to a person or group of persons whaht one believes to
bea falsehood with the intentions of deceiving that person or group of persons.
Narrow definition: intentionally verbalizing what one believes to be a falsehood to a
person or group of persons who have a right to the truth.
Distinction: under broad definition lying is prima facie wrong no matter to whom the
lie is told while under the narrow definition lying is
Pretense: the intentional act of leading a person to adopt or maintain a false belief.
broader than lying because it takes into account non-verbal communication and
leading people onn while not specifically lying.
Lying is: Active and direct while pretense can be active and direct OR passive and
indirect.
