Ethics at the End of Life: Assisted Death

1
Ethics at the End of Life Assisted Death

• ISD II
• Andrew Latus
• June 18, 2003

2
Outline

• End of Life Issues
• Advance Health Care Directives
• Euthanasia

3
End of Life Issues

• Discussions of ethics at the end of life
  generally focus primarily on the dramatic
  issues of euthanasia and assisted suicide
• Today will be no exception
• However, this leaves out ethical issues you may
  encounter more frequently as physicians

4
Patients Perspectives

• Singer et al (1999) report the following end of
  life issues as being of most concern to a group
  of patients surveyed
• Receiving Adequate Pain Symptom Management
• I wouldnt want a lot of pain its one of the
  worst ways to go
• 4 out of 10 dying patients had severe pain most
  of the time?

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Patients Perspectives

• 2. Avoiding Inappropriate Prolongation of Dying
• I wouldnt want life supports if Im going to
  die anyway.
• 78 of health care professionals surveyed thought
  the treatments they offered were too burdensome?
• Problem of getting info about specific
  treatments, but not the big picture
• Role of the physician in giving a realistic
  picture
• 3. Control Over End of Life Decisions
• Its very, very important to me that I can make
  choices for myself.
• More about big picture decisions than narrow
  specific decisions about treatment?

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Patients Perspectives

• 4. Being a Burden on Loved Ones
• Making substitute decisions
• Witnessing their death
• Providing care
• 5. Involvement of Loved Ones
• Considering an advance directive helped me get
  closer to my family There were so many times I
  wanted to get their opinion on certain things

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Advance Health Care Directives

• See material from Geriatrics session
• Notice that many of the issues mentioned by the
  patients could be at least partially dealt with
  via an Advance Health Care Directive
• Caution Dont overestimate the usefulness of an
  AHCD for matters other than identifying a
  decision maker. Its hard to anticipate all
  eventualities.

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Euthanasia

• A broad range of activities are sometimes
  classified as euthanasia
• Withholding treatment
• Withdrawing treatment
• Taking action to end someones life
• Providing someone with the means to end his/her
  life
• What all of them have in common is that they
  involve situations in which
• Someone, perhaps the patient, deems it better
  that the person we are concerned with dies than
  that efforts to treat the patient continue and
• Some course of action or inaction is undertaken
  with the understanding that it will bring about
  the death of the person

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Is Euthanasia Ever Morally OK?

• If we give the term a broad reading, most people
  will answer yes.
• E.g., Suppose Tom has terminal cancer and that
  all conventional treatments have failed.
• Left untreated, he will die in a few days.
• However, there is an experimental drug that has
  shown some promise in treating cancers like his,
  but that also has some very unpleasant side
  effects.
• Few would argue that it is immoral if Toms
  doctors accept his wish to refuse taking part in
  this experiment.
• The question thus becomes under what conditions
  is euthanasia morally acceptable?

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Some Distinctions

• Discussion of particular cases often turns on the
  type of euthanasia involved
• Assisted Suicide
• Voluntary vs. Non-voluntary Euthanasia
• Active vs. Passive Euthanasia

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Assisted Suicide

• Not actually euthanasia, since the 'patient'
  ultimately kills himself or herself.
• The line between the two can, however, become
  very thin.  
• e.g., Dr. Jack Kevorkian's 'Mercitron'  
• Many of the same issues arise in considering
  assisted suicide as in considering euthanasia
• Remaining focus will be on euthanasia

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Voluntary vs. Non-voluntary Euthanasia

• Voluntary - killing or letting die a competent
  person who has expressed a desire for this
  (usually over a sustained period of time).
• Non-voluntary - killing or letting die when the
  patient is unable to express such a desire
• Note there is a difference between involuntary
  and non-voluntary
• Involuntary euthanasia is not a seriously
  considered possibility

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Active vs. Passive Euthanasia

• Active - roughly, involves killing a patient
• E.g., administering a fatal dose of morphine to a
  terminally ill cancer patient
• This is often what people have in mind when they
  simply speak of euthanasia
• Be careful to distinguish killing from murdering
  (wrongful killing) not all killings are
  murders
• Passive - roughly, involves letting a patient die
  
• E.g., failing to revive a patient who has signed
  a DNR order
• Generally, passive euthanasia is looked upon more
  favorably than active euthanasia

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Forms of Euthanasia

• The distinctions may be combined
• Voluntary passive euthanasia (VPE)
• Voluntary active euthanasia (VAE)
• Non-voluntary passive euthanasia (NPE)
• Non-voluntary active euthanasia (NAE)
• VPE is the least controversial form of
  euthanasia 
• a competent patient has a right to refuse
  treatment

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Forms of Euthanasia

• NPE is now broadly accepted in at least some
  situations (e.g., a neonate with almost certainly
  fatal birth defects)
• There are limits, however, e.g., in the Stephen
  Dawson case, S.D.s parents were not allowed to
  refuse lifesaving treatment even though they felt
  S.D. would be better off dead
• Any form of active euthanasia is much more
  controversial, so we will examine the
  active/passive distinction more closely

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Two Kinds of Passive Euthanasia

• (i) Withholding of Treatment e.g., not performing
  a needed surgery or not administering a needed
  drug
• (ii) Withdrawing of Treatment e.g., turning off a
  respirator
• Question  While i above seems clearly passive,
  why is withdrawing of treatment passive?
• Rachels "what is the cessation of treatment ...
  if it is not 'the intentional termination of the
  life of one human being by another'?" (pp. 79-80)
  

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Karen Quinlan

• 1975 - Quinlan goes into a drug induced coma
• Suffers anoxia causing irreversible brain damage
• Required a ventilator to live
• Not brain dead, but in a persistent vegetative
  state
• Quinlans sister - "If Karen could ever see
  herself like this, it would be the worst thing in
  the world for her."
• Hospital - '1 in a million' chance of recovery
• Family sought to have her removed from the
  respirator, doctors hospital refused

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Why Was the Cruzan Case Controversial?

• AMA Declaration (1973)
• The intentional termination of the life of one
  human being by another is contrary to that for
  which the medical profession stands
• The cessation of the employment of
  extraordinary means to prolong the life of the
  body when there is irrefutable evidence that
  biological death is imminent is the decision of
  the patient and/or his immediate family.
  (Rachels, 78)
• Note the word extraordinary
• In 1975, the AMA did not draw a clear distinction
  between withdrawing treatment and active
  euthanasia
• In 1986, the AMA adopted a policy which clearly
  drew this distinction
• CMA Code 17. Ascertain wherever possible and
  recognize your patients wishes about the
  initiation, continuation and cessation of
  life-sustaining treatment.

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The Outcome

• 1976 - N.J. Supreme Court overturns a lower court
  decision and rules in favour of the Quinlans.
• Doctors 'weaned' her off the respirator in a
  successful attempt to keep her alive.
• Died of pneumonia - June 13, 1986
• This case reminds us that standards regarding
  ethical matters can change very quickly.
• The Karen Quinlan case would be much less
  controversial today.
• Is the lesson of the case that the line between
  active and passive euthanasia is uninteresting
  morally speaking?

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Rachels on Active vs. Passive Euthanasia

• Rachels Active euthanasia is not necessarily
  worse than passive euthanasia
• Objection Killing is worse than letting die!
• Response  Rachels claims that we have been
  misled by the fact that most actual cases of
  killing are morally worse than most actual cases
  of letting die
• Because of this, we have mistakenly concluded
  there is some deep moral difference between
  killing letting die.

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Cases

• (i) A unconscious patient will almost certainly
  die unless paced on a respirator. His family
  explain he has expressed a clear desire not to be
  placed on one. He is treated according to those
  wishes and dies.
• (ii) Case i, but the man is placed on the
  respirator before his family arrive. After his
  wishes are explained, he is removed from the
  respirator and dies.  
• Are these cases of killing or letting die?
• Are these cases morally different?

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Cases

• (1) A man drowns his young cousin so that he
  won't have to split an inheritance with him.
• (2) Case 1, except, before he can kill him, the
  cousin slips and falls face down in the bathtub.
  The man just has to watch his cousin drown.  
• Are these cases of killing or letting die?
• Are these cases morally different?

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Cases

• (a) In accordance with an ALS patient's wishes
  the doctors remove her from her respirator. She
  dies.
• (b) A greedy son removes an ALS patient from her
  respirator because he wants to collect his
  inheritance. She dies.
• Are these cases of killing or letting die?
• Are these cases morally different?

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Is Rachels Right?

• Do the cases make a convincing argument that the
  difference between active and passive euthanasia
  is morally irrelevant?
• If so, then what is morally relevant?

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The Law

• Very roughly, the following summarizes the
  Canadian legal situation re. euthanasia
• voluntary passive euthanasia legal
• in fact, required no consent, no treatment
• voluntary active euthanasia illegal
• although see The Doctrine of Double Effect
• not true in all countries (e.g., Netherlands
  since 2001)
• non-voluntary passive euthanasia legal
• under appropriate proxy decision only
• non-voluntary active euthanasia illegal
• although again see The Doctrine of Double
  Effect
• assisted suicide illegal
• not true in all countries, e.g., Oregons Death
  with Dignity Act

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A Closing Issue The Doctrine of Double Effect
(DDE)

• Suppose an action (e.g., giving a terminally ill
  cancer patient morphine) has some reasonably
  foreseeable result (e.g., quickening the
  patients death) and that it would be
  unacceptable to perform this action for the
  purpose of bringing this result about.
• The DDE claims that it may still be acceptable to
  perform this action, provided that the action is
  not performed for the purpose of bringing this
  result about.
• E.g., it may still be acceptable to give the
  patient the morphine provided that it is given in
  order to control his pain, not to hasten the
  patients death
• The DDE is commonly, if not explicitly, appealed
  to in practice.
• As a result, VAE NAE may sometimes be
  practiced.

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The DDE in Practice

• Doctors should feel comfortable giving as much
  pain medication as it takes to ease suffering,
  even if it hastens death The key is a doctors
  intent when giving drugs.
• (CBC story on consensus guidelines re. palliative
  care and analgesia, 2002)
• Does the DDE make theoretical sense?
• Does the DDE make practical sense?