I. ETHICAL ASPECTS

Ethical and legal norms exist in virtually all societies to help protect human life and regulate when taking or not prolonging life is ethically permissible. In most Western societies, the Judeo-Christian religious tradition has given great importance to the sanctity of life. Modern medicine has also gained extraordinary new powers to prolong life. Within the last few decades, medical treatments such as kidney dialysis, cardiopulmonary resuscitation, organ transplantation, respirator support, and provision of food and water by artificial means have become common in hospitals.

While these new treatments often benefit patients, restoring them to well-functioning lives, they also can be employed in circumstances where they may be neither a benefit to nor wanted by patients. Where once pneumonia was the "old man's friend," the way in which "nature" ended a life that had become seriously debilitated, now the time and manner of death has been brought increasingly under human control. In coming to grips with sustaining, taking, or not prolonging life, medicine has drawn on both its own ethical traditions and society's broader ethical and religious traditions.

This entry will first develop an ethical framework for life-sustaining-treatment decisions around which a considerable, though hardly universal, consensus has developed, and contrast it with the distinction between ordinary and extraordinary care. It will then consider broad alternative positions on the morality of taking life and some of their implications for care of the dying. Focusing on more specific controversies, it will then address the intentional taking of life versus pain relief that hastens death, killing and allowing to die, not starting versus stopping treatment, and four prominent examples of end-of-life treatment—resuscitation, artificially administered food and water, terminal sedation and futile treatment. Finally the entry will conclude with discussions of life-sustaining treatment and suicide and of physician-assisted suicide and voluntary euthanasia.

An Ethical Framework for Life-Sustaining-Treatment Decisions

An ethical framework for life-sustaining-treatment decisions should be sufficiently general to apply to all forms of such decisions and to both competent and incompetent patients.

COMPETENT PATIENTS. In the United States in the twentieth century, healthcare-treatment decision making came increasingly under the dominion of the ethical and legal doctrine of informed consent. This doctrine requires that treatment not be administered without the informed and voluntary consent of a competent patient. From a paternalistic and authoritarian tradition, in which the physician made almost all treatment decisions and the patient's role was to follow the doctor's orders, a new ideal emerged that involves shared treatment decision making between physicians and patients. Physicians use their knowledge, experience, and training to determine the patient's diagnosis and prognosis with different possible alternative treatments, including the alternative of no treatment, and the risks and benefits of each. Patients, on the other hand, use their own aims and values to discern and decide which option is best for them. Shared decision making is based on the recognition that sound, individualized-treatment decision making requires both contributions.

The principal ethical values that underlie shared decision making involve promoting the well-being of patients while respecting their self-determination or autonomy. The term well-being is meant to signal that what is best for a particular patient depends not only on the "medical facts" but also on the patient's own aims and values. It is also meant to signal the extremely important point that preserving or sustaining life is not always a benefit to patients; whether it is depends on the nature of the life sustained and whether the patient values that life. Self-determination is the interest ordinary persons have in making important decisions about their lives for themselves and according to their own values or conception of a good life. The capacity for self-determination allows people to take control over and responsibility for their lives and the kind of persons they become. The fundamental importance of self-determination has consistently been the central appeal in the United States both in the long line of informed-consent legal cases going back at least as far as the 1914 case Schloendorf v. Society of New York Hospital, and in the more recent life-sustainingtreatment cases.

On the basis of these two values, as well as the ideal of shared decision making and the requirement of informed consent they support, competent patients have the right to weigh the benefits and burdens of alternative treatments, including the option of no treatment, and to make their own selection. While this ethical framework applies to any treatment, it provides especially strong support for patients deciding about life-sustaining treatment. When forgoing life-sustaining treatment is seriously in question, the patient is often critically or terminally ill and near death and also often in a seriously debilitated state. Whether a particular patient will want to fight to stay alive as long as possible, or will instead at some point find continued life no longer a benefit but now a burden, is highly variable and unpredictable. Self-determination on so important a decision as when and in what ways one's life comes to an end or is sustained by medical treatment is of particular importance.

INCOMPETENT PATIENTS. When forgoing life-sustaining treatment is seriously in question, patients are often— probably usually—incompetent to make the decision for themselves, and so another person must decide for them. Bioethics and the law have given much attention to who should decide about life support for incompetent patients and what standards should be used. A number of ethical grounds support the common practice, employed by physicians and sanctioned by the courts, of turning to a close family member of the patient, when one is available. Most patients would want such a person to make these decisions for them when they are unable to do so; in most cases, then, turning to a close family member respects the patient's self-determination. Moreover, a close family member will usually know the patient best and will therefore be in the best position to determine what the patient would have wanted. This person is also likely to care most about doing what is best for the patient. Turning to a close family member thus promotes both the patient's self-determination and the patient's well-being. Finally, in most societies the family is the social unit in which important social bonds and responsibilities to care for dependent members are developed; one exercise of this responsibility is to serve as surrogate for an incompetent family member. These ethical grounds usually, but do not always, apply and so can be thought of as establishing an ethical presumption that a close family member is the appropriate surrogate to make life-sustainingtreatment decisions for an incompetent patient. When these reasons do not apply—for example, when there is evidence that the patient would have wanted someone else to serve as surrogate or there is a serious conflict of interest between the family member and surrogate—then the presumption in favor of the family member as surrogate can be rebutted and another should be selected to serve instead.

How should a surrogate make life-sustaining-treatment decisions for an incompetent patient? A significant consensus has developed, both in ethics and in law, that there are three standards for a surrogate's decisions. First, if the patient has made an advance directive (e.g., a "living will" or a "durable power of attorney for healthcare") that includes instructions about the individual's wishes as to the decision in question, then the patient's choice expressed in the advance directive should be followed, with only limited qualifications. Second, when most patients do not have an advance directive or their advance directive is too general to determine the actual treatment decision, the "substituted judgment" standard should be used. This directs a surrogate to attempt to make the decision that the patient would have made, in the circumstances that then obtain, if the patient were competent. More informally, the surrogate should use his or her knowledge of the patient and the patient's values and wishes to attempt to decide what the patient would have wanted. Third, when there is no knowledge available of the patient and the patient's values that bear on the decision at hand, the "best-interest" standard should be used. Here, the surrogate should determine what is in the patient's overall best interests by a more objective and communal conception of best interest. This often amounts to asking what most reasonable persons would want; in the absence of available evidence about how, in relevant respects, the patient is different from most people, this is justified. These three standards constitute a way to promote patient well-being and self-determination to the extent possible when the patient lacks capacity to make decisions.

These standards have not gone unchallenged (Meisel; Veatch; Dresser and Whitehead). For example, parents are given significant discretion, especially in the case of young children, in deciding what would be best for their child and are permitted to give some weight to the effects of different options on important interests of other family members. The authority of both advance directives and substituted judgment have also been challenged when following them would conflict with important interests of the now-incompetent patient or when the patient has undergone such profound mental changes that he or she appears to be a "new person" with new interests. Despite the substantial consensus on the ethical framework sketched above, it is not uncontroversial.

This ethical framework for life-sustaining-treatment decisions by competent and incompetent patients does give weight to a narrowly focused quality-of-life judgment: Is the best life possible for the patient with treatment sufficiently poor, according to the patient's evaluation of that quality, that it is worse than no further life at all? No weight is given, on the other hand, to the fact that the patient's quality of life may have diminished from what it once was or from most people's lives, or to any evaluation of the social worth or social value of the patient. The fundamental feature of this ethical framework is that it entitles the patient or surrogate to weigh the benefits and burdens of possible treatments, including the option of no treatment, according to the patient's aims and values, and to select from among available treatments or to refuse any treatment. This decision-making framework has now largely supplanted the distinction between ordinary and extraordinary treatment.

Ordinary versus Extraordinary Care

The distinction between ordinary and extraordinary care has its origins in Roman Catholic moral theology, where it is employed to distinguish between obligatory care—ordinary— and care that may be permissibly forgone—extraordinary. The two central issues about this distinction are: (1) What is the difference between ordinary and extraordinary care? and(2) Why should that difference determine whether care is morally obligatory or optional?

The distinction itself has been criticized as being unclear and resulting in confusion and controversy about how it should be applied (U.S. President's Commission). For example, it has been used to mark the difference between statistically usual and statistically unusual care (perhaps the most commonly held understanding of the terms), between noninvasive and highly invasive treatments, and between treatments that employ low- and high-technology interventions. Because the distinction has many different, natural understandings, confusion often arises about what it means. None of the possible meanings of the distinction explains why the difference itself should determine whether the treatment is morally obligatory or optional. For example, treatment that is statistically common or involves the use of low technology might be beneficial to a particular patient in particular circumstances, but not beneficial or, perhaps, even burdensome to another patient in different circumstances.

The correct understanding of the traditional distinction is the difference between treatment that is beneficial and treatment that is unduly burdensome (or without benefit) to a patient. Of course, treatment is unduly burdensome only when the benefits it provides are insufficient to warrant its burdens. Unlike the other interpretations noted above, this interpretation of the ordinary–extraordinary distinction does mark a morally significant difference. Understood in this way, however, no general list of kinds of treatments that would be consistently ordinary or consistently extraordinary is possible; any treatment may be beneficial in some circumstances but not in others. More important, when the distinction is understood in this way it ceases to be an alternative to the benefit–burden framework. The judgment that a treatment is "extraordinary" places a label on treatment already and independently determined to be without benefit or unduly burdensome to the patient. The benefit–burden assessment does the substantive work in assessing treatments. For this reason, most commentators have given up the ordinary–extraordinary analysis in favor of the clearer and more direct appeal to the assessment of the benefits and burdens of treatment to a particular patient.

Of course, no ethical framework of the sort sketched here can be applied mechanically to make decisions to forgo life-sustaining treatment easy and unambiguous; even with the best efforts and the clearest reasoning, many decisions will remain ethically problematic and emotionally wrenching. While this is also true of many decisions about treatment that is not life sustaining, decisions concerning whether to sustain or shorten life raise several special ethical issues. In the 1960s and 1970s, it was common to distinguish between "active" and "passive" euthanasia. Passive euthanasia was understood to include forgoing life-sustaining treatment, either by stopping it or by not starting it. Active euthanasia was understood to be a deliberate intervention to end a patient's life, for example, by administering a lethal injection. Because euthanasia is often understood to be only active euthanasia, it has become common to avoid the term passive euthanasia in favor of referring to forgoing life-sustaining treatment. Most of these additional ethical issues raised about life-sustaining treatment represent special constraints or limits to be considered regarding the ethical framework just discussed for decisions where life itself is at stake.

The Morality of Taking Life

Any view about the morality of forgoing life-sustaining treatment or of euthanasia will depend in large measure on the basic moral principle presupposed concerning the taking of human life. This principle will differ depending on the general moral theory or conception of which it is a part or from which it is derived. Moral conceptions regarding taking life and killing may be divided into those that are goal-based, duty-based, and rights-based. A goal-based position, of which utilitarianism is the best-known variant, prohibits taking life when doing so fails to maximize the goals or consequences the position holds to be valuable, for example, human happiness or the satisfaction of people's desires. In this view it is a factual matter whether any particular killing produces better consequences than any other available alternative. Because this position not only permits but requires taking an innocent person's life when doing so will produce the greatest balance of benefits over harms, it is in sharp conflict with the patient-centered, ethical framework, which does not permit sacrifice of the patient for the benefit of others.

In a duty-based view, taking life is wrong because it violates a fundamental moral duty not to take innocent human life intentionally. This view looks not to the consequences produced by a particular killing but to the action itself, which is prohibited by the duty not to kill. It is often found within religions that view life as a gift from God, and therefore subject only to God's decision about when to take it. Perhaps the most serious difficulty for this view is its failure to give moral weight to the consent of the person whose life may or may not be taken. In this view, a competent patient's free request that another take her life need not morally justify doing so; instead, it is a request or temptation to do evil and should be resisted by a moral person.

In a rights-based view, taking human life is morally wrong because it violates a basic moral right not to be killed. In this view, killing harms its victims because it denies them their future, together with all that they wanted to pursue or achieve in that future. It wrongs its victims by taking from them without their consent what is rightfully theirs—their lives. In contrast with the duty-based view, however, when a competent individual freely requests that another person take his or her life because that life has become a burden and no longer a good for the individual, that request would be understood to be a waiving of the individual's right not to be killed, and acceding to it would be morally permissible.

The most important, substantive moral difference between duty-based and rights-based views is whether an individual's free and informed consent can make taking the person's life permissible. The distinction between duty-based and rights-based views is a natural way in which this moral difference is often expressed. Nevertheless, the duty not to kill could be understood to apply only to individuals who wish to live, and the right not to be killed could be understood to be unwaivable, as many in the right-to-life movement understand it. The distinction between rightsbased and duty-based accounts of the morality of killing is used in this entry only to distinguish whether an individual's consent to be killed does or does not make killing that individual morally permissible.

Which of these alternative positions is correct is controversial and raises general questions of moral theory that cannot be addressed here. An ethical position that gives fundamental ethical importance to individual self-determination—as the ethical framework for life-sustainingtreatment decisions sketched above does—is most naturally formulated as a rights-based position. Whichever basic view is adopted, however, there are two important questions: (1) What actions are included under the moral prohibition of taking life, broadly construed? and (2) Is this prohibition absolute or does it have exceptions? The duty-based view is sometimes understood to make absolute the prohibition on intentionally taking human life; but it also typically distinguishes acts that intentionally take life from acts in which death is a foreseen but unintended consequence. Both duty-based and rights-based views about the morality of taking life tend to share the position that allowing to die is a less serious wrong than taking a life by killing.

Intended versus Foreseen but Unintended Taking of Life

When caring for dying patients, health professionals sometimes take actions that may shorten the patient's life. They may, for example, provide larger and larger doses of morphine when necessary to relieve a patient's pain, and in doing so, risk bringing on respiratory depression and earlier death. When this is done with the patient's or surrogate's knowledge of the risk and consent, it is morally justified. For the rights-based moral view about taking life, consent to the risk is crucial. In many duty-based positions, however, the consent of the victim does not justify taking human life, and a distinction is drawn instead between whether the resulting death was intended and whether it was only foreseen but unintended.

This intended/foreseen distinction has a long history. Invoked in the thirteenth century by the Italian theologian and philosopher Thomas Aquinas to justify killing in self-defense, the distinction is central to the Roman Catholic doctrine of double effect. (Double effect here refers to actions that may have two effects, one that is directly intended and the other one only indirectly intended or foreseen.) In some form, it is also common in much secular thinking about the morality of taking life.

Two central questions must be answered in order to evaluate whether this distinction really can or should be used to distinguish some morally permissible from impermissible taking of life. First, what precisely is the nature of the difference between "intended" and "foreseen"? Second, why is this difference morally important? In treating a dying cancer patient's pain, it may seem clear that the physician's primary or direct intention is to treat the pain; the earlier death from respiratory depression caused by the morphine the physician prescribes to treat the pain is, at most, a secondary or indirect intention, or more accurately, a fore-seen but unintended consequence. (It is also clinically rare, especially for patients who have been receiving morphine for a considerable period of time.) Many physicians would not give this same patient a lethal injection if all other means of pain relief had failed, because then the death would be intended. Yet the physician's primary intention in the case of killing by lethal injection might also be to relieve the patient's pain, though then the means of doing so is to kill the patient. This distinction between what is intended as a means and what is a foreseen but unintended consequence, however, is not always clear. Killings that seem plainly wrong because they are an impermissible means to a good end can be redescribed as only a foreseen but unintended consequence of achieving the good end, and as, therefore, morally permissible. An extreme example will illustrate the point. Suppose a renowned transplant surgeon removes the heart and liver from a healthy person without the person's consent in order to transplant them in two patients who otherwise will die from heart and liver failure. Such killing is wrong even though it is a means of saving a greater number of persons. But suppose the surgeon denies that the killing is the means of saving other patients: The means of saving the other patients, he claims, was by removing the healthy person's organs and transplanting them, whereas the death of the healthy person was merely foreseen but not intended. Proponents of this distinction have not clarified it in a way that prevents such unwelcome misuse of it.

In many cases, such as giving morphine as opposed to a lethal injection, there is agreement about how to apply the intended-versus-foreseen-but-unintended distinction. The question then arises, what is its moral significance? Critics of the distinction note that in each case the physician's end is to relieve suffering, and that to gain such relief, both physician and patient are prepared to accept the risk of the patient's earlier death. Whether by morphine or a lethal injection, relieving the patient's suffering will bring about an earlier death. These similarities cast doubt on the moral importance of this difference. In the case of morphine, there may be only a risk of death, whereas in the case of a lethal injection the death is certain. But sometimes the amount of morphine necessary makes the likelihood of earlier death extremely high, and then this small difference in probabilities is too slim a foundation for the very great moral difference between permissible and impermissible killings. In any event, this is a difference in the certainty or risk of the outcome of death, not in whether it is intended or unintended.

Critics of the distinction between intended and fore-seen deaths argue that physicians are morally responsible for all foreseen or reasonably foreseeable consequences of their actions, whether intended or foreseen but unintended, because foreseeability brings these consequences under the control of physicians and so makes physicians responsible for them. This disagreement in medical contexts about the moral importance of whether death is intended is often a particular instance of a broader disagreement between goal-based or utilitarian theorists who are concerned only with good results and duty- or rights-based theorists who place moral restrictions on how good results may be brought about.

Killing and Allowing to Die

Many moral theorists distinguish between duties not to kill, called negative duties, and duties to save or not to allow to die, called positive duties (Steinbock and Norcross). They argue that, unless this distinction is used to set reasonable moral limits, moral responsibilities will extend far beyond what they are usually thought to be and will deeply limit people's pursuit of their various life plans. Persons can usually satisfy the duty not to kill simply by pursuing their particular aims and purposes, although these goals may have to be altered if necessary to avoid killing. But if there is an equally stringent duty not to allow to die, it might seem that people must likewise set aside nearly all their usual aims and activities and devote their lives to saving those whose lives are in peril, such as victims of famines or extreme poverty. The implications of whether killing is morally worse than allowing to die are far-reaching both within and outside of medicine.

There are again two distinct issues. First, what makes one particular "doing," understood to include both acts and omissions, a "killing," and another, an "allowing to die"? Once the difference is clear, the second issue is whether and why this difference between killing and allowing to die is morally important. Killing is usually distinguished from allowing to die by establishing whether something was done, or not done, that resulted in death. A person who kills performs an action that causes a person to die in a way and at a time that the person would not otherwise have died. For example, two people are in a boat; Person 1 cannot swim. Knowing this, Person 2 pushes Person 1 out of the boat; Person 1 drowns.

A person who allows another to die knows that there is an action she could perform that would prevent another's death, but she does not take this action, and the person dies. For example, Person 1 accidentally falls out of the boat. Person 2 does not throw out an available life preserver, and Person 1 drowns. Some philosophers have argued that if the difference between killing and allowing to die is predicated on acting or not acting, killing is not morally worse than allowing to die.

The meaning of this claim has often been misunderstood. The claim is that the mere fact that one doing is a killing, while the other is an allowing to die, does not make one morally better or worse than the other, or make one morally justified or permissible when the other is not. This is compatible with saying that a particular killing, all things considered, is morally worse than, or not as bad as, a particular allowing to die because of other differences between the two, such as the motives of the agents or the presence or absence of the consent of the victim. This is also compatible with holding that most killing, all things considered, is morally worse than most allowing to die, but once again, that must be because of other morally important differences between them.

The usual argument for the position that killing is not in itself morally worse than allowing to die has consisted of comparing two cases that differ in no other morally relevant respect except that one is a killing, the other an allowing to die. Such a comparison helps focus on whether this difference by itself is morally important. James Rachels provided the following well-known example:

In the first [instance], Smith stands to gain a large inheritance if anything should happen to his six-year-old cousin. One evening, while the child is taking his bath, Smith sneaks into the bathroom and drowns the child, and then arranges things so that it will look like an accident.

In the second, Jones also stands to gain if anything should happen to his six-year-old cousin. Like Smith, Jones sneaks in planning to drown the child in his bath. However, just as he enters the bathroom Jones sees the child slip and hit his head, and fall face down in the water, Jones is delighted; he stands by, ready to push the child's head back under if it is necessary, but it is not necessary. With only a little thrashing about, the child drowns all by himself, "accidentally," as Jones watches and does nothing. (1975, p. 79)

Whereas Smith killed, Jones allowed to die. Rachels argued that there seems to be no basis for saying that what Smith did was any worse than what Jones did; there must be other factors in real cases that account for any moral differences. The conclusion that killing is not, in itself, morally worse than allowing to die remains controversial. Those who hold that there is a significant moral difference between the two argue that it is important to establish which of the two types of forgoing of life support, if either, comes under the stronger moral prohibition against killing. Because forgoing life support includes both not starting treatment and stopping treatment, the issue of whether either is equivalent to killing can be pursued by asking whether or not starting life support and stopping life support are morally different.

Not Starting Treatment and Stopping Treatment

When a decision is made not to initiate some form of life-sustaining treatment, such as kidney dialysis or respirator support, and the patient dies as a result, this is commonly understood to be an omission and so an allowing to die. Even if active killing is wrong, its prohibition does not apply to not initiating life support. But what of stopping life support—for example, stopping respirator support at the persistent, voluntary request of a clearly competent and respirator-dependent patient who is terminally ill and undergoing suffering that cannot be adequately relieved? If such action is taken by the physician with the intent of respecting the patient's right to decide about his or her treatment, most people would consider it a morally justified instance of allowing the patient to die. If only killing, but not allowing to die, is prohibited, then stopping life support and not starting it are both allowing to die and morally permitted.

But some philosophers have argued that stopping this patient's respirator is killing, not allowing to die (Brock). Suppose, for example, the patient has a greedy son who mistakenly believes that his mother will never decide to stop treatment and that even if she did, her physicians would not comply with her wishes. Afraid that his inheritance will be exhausted by a long hospitalization, he enters his mother's room while she is deeply sedated and removes her from the respirator, and she dies. If upon being found out, the son protested, "I didn't kill her; I merely allowed her to die; it was her disease that caused her death," this claim would be rejected. The son went into his mother's room and deliberately killed her.

Does the physician who did the same thing, performed the same physical action, kill the patient as well? Even if the physician in such a case does kill, other moral differences make the physician's killing morally justified, whereas the son's is morally wrong. The physician acts with a good motive, to respect the patient's wishes, with the patient's consent, and in a professional role in which the physician is socially and legally authorized to so act; the son acts with a bad motive, without consent, and with no social or legal authorization to do so. But these do not appear to be differences in whether either kills or allows to die: One can kill or allow to die with a good or bad motive, with or without consent, and in or not in a role that authorizes the action.

Those who reject this analysis and hold that stopping and not starting life support are both allowing to die usually have a different account of the kill/allow-to-die difference than the act/omission account offered in the last section. They hold that when a patient has a lethal illness such as lung disease, whose usual fatal outcome is being held off by a life-sustaining treatment such as a respirator, removing this artificial intervention amounts to allowing the patient to die by letting the disease process proceed unimpeded to death. But this account is problematic, not least because it requires one to accept that the greedy son also allows to die, but does not kill.

Whether stopping life support is killing or allowing to die, some physicians and others have contended that it is an ethically graver matter to stop a life-sustaining treatment than not to start it, or that it is permissible not to start it in circumstances in which it would not be justified to stop it. But consideration of cases such as the following has led most persons to reject the argument that stopping life support is different from or more serious morally from not starting it:

A gravely ill patient, Mr. S, arrives at the hospital in respiratory distress and is sent to the intensive care unit (ICU) to be intubated and placed on a respirator. Before he is intubated, his family and physician arrive at the ICU and inform the staff that while clearly competent Mr. S, after extensive consideration and because of his debilitated and terminal condition, had firmly rejected being put on a respirator under any circumstances. The ICU staff respect his wishes, keep him comfortable, and he dies of respiratory failure. Now suppose instead that heavy traffic had delayed the family and the physician and they arrive at the ICU just after Mr. S is put on the respirator. His treatment now must be stopped instead of not started as before. (Brock, p. 209)

It is hard to see why the same factors that morally justified not starting his treatment do not, equally, morally justify stopping it.

Those who hold that stopping life support is not different ethically from not starting it usually stress two bad effects of a greater reluctance to stop life support. First, it will result in continuing treatment beyond the point at which it is a benefit to or still wanted by the patient. Second, and less obvious but at least as important, the belief that it will be harder to stop life support once it is begun can make physicians, patients, and family members all reluctant to try treatment when the benefits are uncertain or unlikely, for fear that if the treatment proves not to be beneficial they will not be able to stop it and the patient will end up "stuck on machines." The result is to deny patients possibly beneficial life-sustaining treatment.

In fact, there is often better reason to stop a life-sustaining treatment than not to start it. Often, before a life-sustaining treatment is started, it is uncertain whether it will bring the hoped-for benefits to the patient. Once it has been tried, and it is clear that it does not produce the benefits sought, a reason exists for stopping it that did not exist for not starting it. This supports the use of time-limited trials of life-sustaining treatment, with the understanding that if the treatment does not prove to be beneficial it will be stopped.

Four Kinds of End-of-Life Treatment

Four forms of treatment of patients near death that have received special attention are resuscitation, artificial nutrition and hydration, terminal sedation, and so-called futile treatment.

RESUSCITATION. Life-sustaining-treatment debates in the United States during the 1970s and 1980s often focused on the use of cardiopulmonary resuscitation (CPR) for persons who suffer cardiac or pulmonary arrest. Because CPR, to be effective, must be administered immediately after a patient suffers an arrest, hospitals have developed policies generally requiring that CPR be administered to any such patient, unless there is a "do not resuscitate" (DNR) order already in effect for the patient. The presumption of these policies— that anyone in medical need of resuscitation should receive CPR unless there was a prior order not to use it—made CPR different from many other life-sustaining treatments, which required a physician's explicit order to start them.

CPR is the most prominent example of a class of emergency procedures for which consent is presumed unless the patient or the patient's surrogate has explicitly refused it beforehand. Because CPR in the hospital is usually not successful, is associated with significant morbidity for the patient even when it is successful, and often would, at best, extend the lives of dying patients only briefly, there is widespread consensus that forgoing it is often ethically justified so long as patients or their surrogates agree and explicitly withdraw the presumption of consent for it. As a result, resuscitation, or "code status," is probably the most frequently raised life-sustaining-treatment decision.

ARTIFICIAL NUTRITION AND HYDRATION. Those who seek to limit the life-sustaining treatments which it is ethically permissible for patients or their surrogates to decide to forgo have usually focused on the provision of nutrition and hydration by artificial means, such as intravenous, nasogastric, and other forms of tube feeding. Some people have argued that food and water are not medical treatment but are instead the most basic form of caring for dependent persons; all people, not just medical patients, need food and water. Others argue that when the patient's medical condition necessitates the artificial provision of food and water, and when this is done by medical personnel using medical means, there is not much difference between this situation and the provision of oxygen by respirators to patients with lung disease.

Other opponents of forgoing food and water focus not on the issue of whether it is medical treatment, but on the strong symbolic meaning and importance of feeding those in need. The usual symbolism of food and water, however, may be misleading in the circumstances in which the question arises in medicine. There the cultural and social symbolism and meaning associated with eating and feeding are largely absent, as is the suffering typically associated with starvation. Applying the benefits-and-burdens analysis, food and water should be forgone only if doing so would not cause significant suffering to the patient. The benefits-and-burdens analysis will support forgoing nutrition and hydration either when continued life itself is burdensome or not a benefit to the patient, or when providing nutrition and hydration increases, rather than decreases, the patient's suffering. For example, many patients in a persistent vegetative state—that is, those who have permanently and completely lost the capacity for any conscious experience—would not want nor consider it a benefit to have their lives continued. Consequently, treatment that sustains life is not beneficial, and its withdrawal cannot impose any burden on such a patient. In other cases, providing normal levels of nutrition and hydration may increase the awareness and suffering of some dying patients; for these patients, feelings of thirst can be assuaged, for example, with ice chips, without providing a level of hydration that would make their dying less peaceful and comfortable (Lynn). In still other cases, the benefits of continued life for seriously demented patients must be weighed against the burdens of physical restraints necessary to keep them from removing feeding tubes.

A different form of forgoing food and water can occur when a competent patient refuses them because the patient wishes to die. Some have argued that because competent patents always have not only the right to refuse artificially provided nutrition and hydration but also the right to refuse to eat or drink by ordinary means, physician-assisted suicide is an unnecessary option. Refusing to eat or drink will always result in the patient's death, and so a competent patient who wishes to die but who does not have any life-sustaining treatment to be forgone does not need access to physician-assisted suicide to do so. Stopping eating and drinking, however, can take considerable resolve on the patient's part and may not meet many patients' views of a humane and dignified death. Proponents argue that it still may be a better policy option than physician-assisted suicide if the latter has substantial risks that stopping eating and drinking does not have.

TERMINAL SEDATION. Related to stopping nutrition and hydration as an alternative to physician-assisted suicide is the use of terminal sedation (Quill, Lo, and Brock). This typically involves sedating a patient with otherwise intractable pain to the point of unconsciousness and then withdrawing nutrition and hydration, with the inevitable result of the patient's death. Terminal sedation is used by some hospices and is defended as an acceptable practice because treating patients' pain is an uncontroversial responsibility of physicians and withdrawing nutrition and hydration is within patients' general right to refuse any treatment. The practice remains controversial, however, both because it raises the previously discussed problems with the distinction between intended and foreseen but unintended consequences, and because it is subject to abuse, especially if employed with incompetent patients. Others argue that because it may take up to a week or more for the patient to die, physician-assisted suicide would usually provide the patient with a preferable death.

FUTILE TREATMENT. A final recent controversy concerns futile care. As physicians have come to accept patients' rights to refuse treatment, they have increasingly encountered patients, or more commonly the families of incompetent patients, demanding treatment that the physicians judge to be futile. The debate began with CPR but has expanded to other forms of life-sustaining care. When physicians are asked to actively provide a treatment, it has seemed to many that the treatment should be acceptable both to the patient and to the physician; typically, in any joint enterprise, such as that between patient and treating physician, what is done must be acceptable to both participants. This may help account for the asymmetry many support between patients' right to refuse any treatment but to choose only from among medically acceptable alternative treatments.

A central issue in the futility debate has been how to define futility. Some have tried to narrowly restrict it to only those treatments known with certainty not to achieve their goal. The attempt is to eliminate value judgments from futility determinations and to make them only an empirical matter about which the physician should be expert. But others have pointed out that it is not possible to eliminate all value judgments. How certain is certain enough, and what are the legitimate goals of the treatment? Others have more broadly characterized futility to include cases in which the probability of benefit is considered too low, or the size of benefit too small, to warrant the burdens of the treatment. Here, the value judgment in determining futility is whether the treatment's benefits are likely enough, or large enough, to warrant its burdens. This value judgment seems in most cases appropriately left to the patient or surrogate, not the physician. The courts that have addressed futility cases have largely sided with patients or surrogates seeking treatment rather than with physicians who wish not to provide it.

Life-Sustaining Treatment and Suicide

Suicide is difficult to define precisely but is usually understood as the intentional taking of one's own life. In some religious traditions, suicide has long been and continues to be prohibited and considered a sin, and some important moral philosophers such as Immanuel Kant (1724–1804) have held that suicide is morally wrong (Battin). Historically, the law often reflected these views, although in the United States no states now criminalize suicide or attempted suicide, but a majority prohibit assisting in suicide.

The different, basic moral positions discussed earlier on the morality of taking human life have different implications for the morality of suicide. Despite these differences, most people agree that a public policy of seeking to prevent most suicide attempts is morally justified. Even strong defenders of individual self-determination generally agree that most suicide attempts are dramatic pleas for help and occur when a person's decision-making capacity is seriously disordered by such conditions as depression. These features justify intervention to prevent the suicide, so as to determine if the patient is competent and not subject to impaired decision making, in which case, some believe, others should cease coercive interference.

Because a patient's decision to forgo treatment correctly believed to be life-sustaining will result in the patient's death, the question arises whether this is suicide. In some cases, the patient may not intend her own death, or seek death, but only be unwilling to undergo the burdens of a particular life-sustaining treatment. In other cases, however, the patient's decision may also be made in the interest of seeking an end to an excessively burdensome existence; in such cases, therefore, there is an intent to cause one's own death, making it hard to differentiate the decision from suicide. Many legal decisions about life-sustaining treatment, and most Western religious traditions, have sought to distinguish forgoing life support from suicide, often by characterizing the former as an exercise of self-determination about one's medical treatment, not intentional self-destruction. (The courts may have sought to distinguish forgoing life support from suicide to protect participating physicians and others from potential prosecution under legal statutes prohibiting assisting in suicide.) Yet the normative judgment a competent person makes justifying each act is often essentially the same: The best future life possible for me (with life-sustaining treatment, in the case of a decision to forgo treatment) is so bad that it is worse than no further life at all. The principal difference between some cases of forgoing life-sustaining treatment and suicide appears to be only a difference in the means a person uses to bring about her death. Nevertheless, even if some or all forgoing of life support is essentially suicide, it need not, for that reason, be morally wrong, but might instead be considered a justified exercise of self-determination.

Physician-Assisted Suicide

In nearly all countries, neither professional practice nor the law permits physicians to grant patients' requests for physician-assisted suicide or voluntary euthanasia. An example of physician-assisted suicide is when a patient ingests a lethal substance provided by a physician for that purpose; voluntary euthanasia, by contrast, involves the physician administering the lethal substance. In both cases, the choice rests fully with the patient, and the patient can change his mind up until the moment the lethal process becomes irreversible. The only difference need be who performs the last physical action of administering the lethal dose, for example, placing potassium chloride in the patient's intravenous line. This small difference in the part played by the physician in the causal process leading to death does not seem to support a substantial moral difference between physician-assisted suicide and voluntary euthanasia.

Those who nevertheless believe that it is morally worse for physicians to perform voluntary euthanasia than physician-assisted suicide can argue that in the former, the physician kills the patient, whereas in the latter, the patient kills herself. But it may be more accurate to say that in physician-assisted suicide, the physician and the patient together kill the patient—a case of joint action for which both together bear responsibility. This suggests that physician-assisted suicide and voluntary euthanasia may not be substantially different morally.

Voluntary, Active Euthanasia

Considerable public and professional attention, spurred by publicity about the practice in the Netherlands (Van Der Maas, Van Delden, and Pijnenborg) and several notorious cases in the United States, such as those of Dr. Jack Kevorkian, has focused on voluntary, active euthanasia. In significant part, the public interest in euthanasia reflects fear of loss of control and dignity while dying. It also reflects recognition that the same values of patient self-determination and well-being that have been accepted as guiding treatment decision making in general, and decisions about life-sustaining treatment in particular, can in some cases support voluntary, active euthanasia as well. If this positive support for voluntary euthanasia is granted, opponents have in general offered two kinds of arguments against it.

The first argument is that any individual instance of euthanasia is morally wrong because it violates the duty not to kill innocent human beings. As noted earlier, in some duty-based accounts of the wrongness of killing, the consent of the one killed does not make the killing permissible. Nevertheless, given the centrality of the patient's consent in ethical accounts of the permissibility of forgoing life-sustaining treatment, some special argument is needed for why consent has no relevance for euthanasia. Moreover, if the argument in the earlier section on killing and allowing to die is correct—that some stopping of life support is justified killing—then euthanasia cannot be morally condemned simply because it is killing. Many duty-based moral accounts of the wrongness of killing either implicitly or explicitly depend on theological premises that give God sole dominion over life and death. However, in pluralistic societies that respect religious freedom, public policy should not be based on religious beliefs that many members of that society do not share. The rights-based account of the wrongness of killing, however, gives decisive weight to the consent and self-determination of the patient who seeks it.

The other general kind of argument against euthanasia is that although it may be morally permissible in some individual cases, it would nonetheless be bad public policy to permit voluntary, active euthanasia. This argument depends on an assessment of the likely good and bad consequences of permitting euthanasia, only a few of which can be noted here. Among the potential good consequences that proponents cite are: respecting the self-determination of those who request euthanasia but have not been able to get it; assuring the much larger number of people who believe it should be permitted so that should they request it, it would be available; ending the pain and suffering of dying patients that cannot be relieved by any other means; and providing for some patients a more humane and peaceful death than they would otherwise have.

Among the potential bad consequences opponents cite are: its apparent incompatibility with the aim of medicine of protecting life in all its frailty; the erosion of the trust of patients in their physicians as caregivers; the erosion of the social commitment to provide appropriate care to the dying if euthanasia, in an era of cost containment, is seen as an acceptable and cheaper alternative; and fear that permitting voluntary euthanasia would, over time, lead to involuntary euthanasia, or at least to nonvoluntary euthanasia of incompetent patients. Evaluating the likelihood and relative seriousness of these and other possible good and bad consequences of permitting either physician-assisted suicide or voluntary euthanasia is difficult and controversial. In 2003 in the United States, physician-assisted suicide is legal in the state of Oregon, and that state's accumulating experience with the practice is the basis for considerable debate (Sullivan, Hedberg, and Hopkins; Nuland). Whether either practice should be permitted remains one of the most deeply controversial issues in medical ethics.

Conclusion

Since the 1960s, the capacity of medicine to prolong patients' lives has steadily increased, making the time and circumstances of a person's death increasingly a matter of human choice and control. The debates considered and the ethical framework for life-sustaining-treatment decisions sketched in this entry have been responses to this new control over how and when humans die. Perhaps the central feature and accomplishment of the great public and professional attention to death and dying in recent decades has been securing the rights of patients or their surrogates to decide about care near the end of life together with focusing the medical profession's attention on improving care at the end of life. However, the deeply personal, emotionally complex, and ethically controversial nature of decisions about care at the end of life ensures that they will continue to be a prominent part of bioethics.

dan w. brock (1995)

revised by author

SEE ALSO: Advance Directives and Advance Care Planning; Anthropology and Bioethics; Autonomy; Clinical Ethics; Competence; Death; Death, Definition and Determination of; Dementia; Healthcare Resources, Allocation of; Holocaust; Informed Consent; Long-Term Care; Medical Codes and Oaths; Metaphor and Analogy; Palliative Care and Hospice; Right to Die: Policy and Law;Surrogate Decision-Making; and other Life Sustaining Treatment and Euthanasia subentries

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