EUTHANASIA

Euthanasia used to refer to an easy and gentle death, but it has come to refer to methods of inducing that kind of death, or more precisely, methods of bringing about death sooner and usually with less pain and suffering. Euthanasia used to be limited to patients in the terminal stage of an illness, but it is now thought to be appropriate in some cases of nonterminal patients, for example, those in a persistent vegetative state and those suffering from an incurable and very painful chronic disease such as multiple sclerosis.

Voluntary Active Euthanasia

Voluntary active euthanasia (VAE) is when a physician accedes to a rational request of an adequately informed, competent patient to be killed, for example, with a lethal intravenous injection of pentothal.

Physician-Assisted Suicide

Physician-assisted suicide (PAS) is when a physician, at a rational request of an adequately informed, competent patient who plans to commit suicide, knowingly provides that patient with the medical means to commit suicide and the patient uses those means to commit suicide.

Voluntary Passive Euthanasia

Voluntary passive euthanasia (VPE) is when a physician abides by a valid rational refusal of treatment by an adequately informed, competent patient knowing that doing so will result in the patient dying, for example, complying with the refusal of a ventilator-dependent patient with motor neuron disease to receive further mechanical ventilatory support. Abiding by patient refusal of hydration and nutrition (PRHN) is another example of VPE, as is abiding by such refusals given in advance directives—either living wills or durable powers of attorney for health care—even though the patient is incompetent at the time the treatment is withheld or withdrawn.

Patients are competent to make a decision about their health care if they have the ability to make a rational decision. This requires both that they have no relevant mental disorder that prevents them from making a rational decision and that they have the capacity to understand and appreciate all the information necessary to make that decision. They are adequately informed when they have all the information necessary to make a rational decision. Patient competence, having adequate information, and no coercion by the health care team, are the elements of valid (informed) consent or refusal of treatment. If participation in research or donating an organ, rather than treatment, is involved, coercion by anyone invalidates consent.

Decisions by patients are irrational if they know the decisions will result in serious harm to them, for example, death, chronic pain, or significant disability, and they do not have adequate reasons for suffering that harm, for example, beliefs that some people, either themselves or others, will thereby avoid suffering an equal or greater harm by that decision. Only those decisions count as irrational that result in the person suffering significant harm and for which almost no one in the person's culture would rank the benefit gained or harm avoided as providing an adequate reason. Often, however, rational people rank harms in different ways; for example, it is rational to rank several months of suffering from a chronic or terminal disease as worse than death and it is also rational to rank death as worse.

Involuntary Active Euthanasia

Involuntary active euthanasia (IAE) is the killing of a patient who is suffering in order to relieve that suffering but without a request from the patient to be killed. This is most likely to occur with permanently incompetent patients who are unable to make such a request.

Involuntary Passive Euthanasia

Involuntary passive euthanasia (IPE) is allowing a suffering patient to die by ceasing treatment, in order to relieve that suffering, when the patient has neither refused that treatment nor has an advance directive refusing that treatment. This is most likely to occur with permanently incompetent patients who are unable to refuse treatment and do not have an advance directive refusing that treatment. Ceasing treatment for permanently incompetent patients who do not have advance directives refusing that treatment but who have communicated to their families that they would not want to live in this kind of condition, is usually considered to be VPE rather then IPE.

As of 2005, VAE and IAE are illegal in every state in the United States, but PAS is legal in Oregon, and many people have begun to argue for its legalization in other states. IPE is also illegal, except when continuing treatment is considered futile, but almost all those who do bioethics hold either that the definition of futility be broadened so that all treatment of patients in a persistent vegetative state be classified as futile or that some other method be established that allows discontinuing all treatment, including hydration and nutrition, for those in a persistent vegetative state when there is no religious reason for the treatment to be continued.

The United States Supreme Court has explicitly distinguished between VPE and PAS, and by consequence, VAE, holding that only the former is based on a fundamental right to be left alone. The Court correctly regards terminal sedation, that is, being sedated to unconsciousness until one dies, as VPE for those patients who have refused hydration and nutrition and whose pain and suffering cannot be controlled in other ways. VPE is approved by the American Medical Association and all other medical and legal organizations. Philosophers have attempted to provide an account of VPE that explains its almost universal acceptance. All of these attempts have identified VAE with killing and VPE with allowing to die. Two of the most common ways of distinguishing between VAE (killing) and VPE (allowing to die) are (1) acts versus omissions and (2) withholding versus withdrawing.

The philosophical distinction between acts and omissions seems a natural way to distinguish between killing and allowing to die. On this account, if a physician does something, for example, injects an overdose of morphine or turns off the respirator, that is an action and should count as VAE, should be considered killing, and should be prohibited. If the physician does nothing but, rather, simply fails to do something, for example, does not turn on the respirator or does not provide essential antibiotics, that is an omission and should count as VPE, should be considered allowing to die, and should be permitted. However, it seems pointless to distinguish between an authorized physician who turns a knob that stops the flow of life-sustaining antibiotics and one who omits filling the bag when it runs out of those antibiotics. Those who have used the distinction between acts and omissions to distinguish between VAE and VPE have usually concluded that the distinction has no moral significance.

The distinction between withholding and withdrawing treatment seems to have great appeal for some doctors as a way of distinguishing between killing and allowing to die. Some maintain that if patients validly refuse to start a life-saving treatment, doctors do not have a duty to force it on them and so are only allowing them to die. However, once treatment is started, if discontinuing it would lead to the patient's death, they have a duty to continue, and it is killing not to do so. Doctors are not required to force patients to go on the ventilator if they refuse, but once patients have accepted going on the ventilator, doctors have a duty to keep them on if taking them off would result in their death, even if they have had a change of mind.

As with the previous distinction between acts and omissions, there seems to be no morally significant difference between withholding and withdrawing treatment. Physicians do not have a duty to continue treatment if an adequately informed, competent patient rationally refuses to have it continued. Imagine two unconscious patients who are going to be put on a respirator; one becomes conscious before being put on and the other after being put on, but both are competent, adequately informed, and rationally refuse treatment. This accident of timing is morally irrelevant. Further, this way of distinguishing between active and passive euthanasia may create serious practical problems. Patients who had not been adequately evaluated (often at the scene of an accident) may be judged inappropriate for rescue efforts because the doctors believe that once the patient is on a ventilator they cannot legitimately withdraw it.

The inadequacy of these two attempts to distinguish between VAE and VPE has led many to doubt that there is a morally relevant distinction between them. However, closer attention to the way the distinction is actually made, both in law and medicine, shows that what was overlooked is the crucial role played by the patient. When a patient rationally and validly refuses what is offered, the physician is legally and morally required not to overrule that refusal. Abiding by a valid rational refusal, knowing that death will result, counts as VPE whether this involves (1) an act or an omission or is (2) withholding or withdrawing. That everyone acknowledges that a physician must abide by a valid refusal of treatment, whether this involves an action or is a case of withdrawing, explains why VPE is almost universally considered to be morally acceptable.

If a patient requests the physician to do something, however, the physician is not morally required to do it if in the physician's judgment it is inappropriate to do so. Physicians may accede to patient requests if they regard them as appropriate, but rarely are they required to do so. If a patient requests that a doctor do something illegal or that the doctor considers immoral, the doctor usually is not required to accede to that request. Killing patients at their rational request is illegal, and even if it were to be legalized, many physicians would still consider it to be immoral. Even granted that it is sometimes morally acceptable for physicians to kill patients at their request, it will never be legally or morally required for them to do so. This is sufficient to distinguish VAE from VPE, for it is legally and morally required for physicians to abide by the rational valid refusals of their patients.

Confusion sometimes arises because a patient's refusal is framed as a request. For example, a patient's request that no cardiopulmonary resuscitation (CPR) be attempted counts as a refusal of permission for CPR. Similarly, written advance directives requesting the cessation of other therapies or of hydration and nutrition, count as refusals. Any request for not starting or stopping a treatment is a refusal of treatment, and if the patient is competent and the request is rational, doctors are morally and legally required to abide by it.

Distinguishing between refusals and requests becomes more difficult when the life-prolonging treatment is provided by a device such as a pacemaker that has been implanted in the patient. Even though a pacemaker can be reprogrammed to cease functioning without any surgical procedure, some have considered the pacemaker to have become part of the person and so regard the request to turn it off as a genuine request and not as a refusal. However, the dominant view is that whether the artificial device that is keeping the person alive is inside or outside is not the important consideration. If the device can be turned off from the outside, then the patient's request can be counted as a refusal and should be honored. However, because it is not clear that the patient's request should be counted as a refusal, it is not clear whether the doctor is legally required to have the pacemaker turned off. On the other hand, if a surgical procedure is required, for example, to take out an implanted heart valve, no one would count the request to have it taken out as a refusal, and if any doctor agreed to such a request, that doctor would be regarded as having killed the patient.

Using valid refusal versus requests as the way of distinguishing VPE from VAE, while it explains the moral acceptability of VPE, does not make VAE morally unacceptable. Given present knowledge and technology, a physician can kill a patient absolutely painlessly within a matter of minutes. If there were no way for patients to shorten the time of their dying or for their pain to be controlled, VAE would seem to be clearly morally acceptable. However, PRHN, which, contrary to common belief, does not cause suffering, normally results in patients becoming unconscious within a week and dying within another week, and there is no limit on ways to control their other pain during that time. Because all proposals to legalize VAE or PAS involve at least a two-week waiting period, it seems pointless to argue for legalizing VAE or PAS, which are controversial, rather than providing education about PRHN, a form of VPE, which is already universally accepted. Failure to appreciate the available alternative of PRHN makes arguments such as those presented to the Supreme Court in The Philosopher's Brief in favor of declaring Washington and New York states prohibition of assisted suicide unconstitutional far less persuasive than they otherwise would be.

Abiding by the refusal of an advance directive of a competent patient, when that patient becomes incompetent, is also regarded as VPE. If competent patients explicitly state in advance directives that should they become permanently incompetent they want all life prolonging treatments to be discontinued, then the physician is morally required to abide by that refusal. However, some challenge this view, claiming that the views of the competent person who filled out the advance directive may not be the same as the views of the incompetent person to whom they are being applied. Some hold that advance directives need not be followed if the physician believes that the incompetent person would no longer choose to have life-prolonging treatment withdrawn. A public policy must be judged, however, in terms of the effects that this policy would have on everyone affected if all of them knew of the policy. Competent persons who fill out advance directives refusing life-prolonging treatment if they become permanently incompetent consider it distasteful and devoid of dignity to live as a permanently incompetent person, but after becoming permanently incompetent, the person, having no sense of dignity, does not view life with distaste.

If everyone knew that advance directives would not be honored in these cases, some permanently incompetent persons would live longer than they would if such advance directives were honored. This might be a positive result although it is not clear whether the incompetent person views it in that way. However, it is clear that another result of everyone knowing that their advance directives would not be honored would be anxiety, anger, and other unpleasant feelings by those competent persons who had made out such advance directives. This could result in an increase in deaths of such competent persons in order to avoid the unwanted prolongation of their lives as incompetent persons. That the public policy of honoring advance directives is likely to have better consequences than the public policy of not honoring them justifies the policy.

See also Applied Ethics; Bioethics; Medical Ethics.

Bibliography

Battin, Margaret P., Rosamond Rhodes, and Anita Silvers. Physician Assisted Suicide: Expanding the Debate. New York: Routledge, 1998.

Bernat, James L., Bernard Gert, and R. Peter Mogielnicki. "Patient Refusal of Hydration and Nutrition: An Alternative to Physician-Assisted Suicide or Voluntary Euthanasia." Archives of Internal Medicine 153 (1993): 2723–2728.

Brock, Dan W., Life and Death (especially pp 95–232). Cambridge, U.K.: Cambridge University Press, 1993.

Clouser, K. Danner, "Allowing or Causing: Another Look." Annals of Internal Medicine 87 (1977): 622–624.

Dresser, Rebecca S. and John A. Robertson. " Quality of Life and Non-treatment Decisions for Incompetent Patients." Law, Medicine & Health Care 17 (3) (1989): 234–244.

Dworkin, Ronald, Thomas Nagel, Robert Nozick, John Rawls, Thomas Scanlon, Thomas, and Judith Jarvis Thomson, as amici curiae in Supreme Court cases: Washington et al. v. Glucksberg et al. and Vacco et al. v. Quill et al. (Known as The Philosopher's Brief ), 1996.

Gert, Bernard, Morality: Its Nature and Justification. Rev. ed. New York: Oxford University Press, 2005.

Gert, Bernard, Charles M. Culver, and K. Danner Clouser. Bioethics: A Systematic Approach. Oxford University Press, 2006.

The Hastings Center. Guidelines on the Termination of Life Sustaining Treatments and Care of the Dying. Bloomington: Indiana University Press, 1987.

Lynn, Joanne, ed. By No Extraordinary Means: The Choice to Forego Life-Sustaining Food and Water. Bloomington: Indiana University Press, 1986.

President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to Forego Life-Sustaining Treatment. Washington, DC: Government Printing Office, 1983.

Quill, Timothy E. Death and Dignity. New York: Norton, 1993.

Rachels, James. "Active and Passive Euthanasia." New England Journal of Medicine 292 (1975): 78–80.

Rachels, James. The End of Life: Euthanasia and Morality. New York: Oxford University Press, 1986.

Van er Maas, Paul J. et al. "Euthanasia and Other Medical Decisions concerning the End of Life." Lancet 338 (1991): 669–674.

Supreme Court Decisions: Washington et al. v. Glucksberg et al. and Vacco et al. v. Quill et al., 1997.

Wanzer, Sidney J. et al. "The Physician's Responsibility Toward Hopelessly Ill Patients: A Second Look." New England Journal of Medicine 320 (1989): 844–849.

Weir, Robert F. Abating Treatment with Critically Ill Patients. New York: Oxford University Press, 1989.

Bernard Gert (2005)