Euthanasia

• voluntary euthanasia

  When a person's life is ended at their request or with their consent.
• non-voluntary euthanasia

  When a person's life is ended without their consent but with the consent of someone representing their interests e.g. when the person is in a persistent vegetative state.
• sanctity of life

  A religious concept that human life is made in God's image & is therefore sacred in value.
• quality of life

  A largely secular idea that humans life has to possess certain attributes in order to have value.
• active euthanasia

  A treatment is given that directly causes the death of the individual.
• passive euthanasia

  A treatment is withheld & this indirectly causes the death of the individual.
• sanctity of life

  -both voluntary & non-voluntary euthanasia seem to contradict the religious belief in the sanctity of life

  -this is a belief in the value & sacredness of life that is shared by many religious believers

  -in Christianity, this value comes from being created in the image of God

  --> this means it is morally wrong to take life

  -Catholic Christians place weight on the NL & the teachings of the Church in addition to biblical evidence

  -in NL, the primary precept of preserving innocent life establishes the importance of the sanctity of life

  -the Church has officially pronounced against euthanasia, particularly in the 1980 Declaration on Euthanasia
• biblical quotes

  -"so God created mankind in his own image, in the image of God he created them" (Genesis 1:27)

  --> image of 'God' may refer to the capacity for rationality or the ability to make moral decisions (this divine image gives human life value)

  -"you shall not murder" (Exodus 20:13)

  --> one of the Ten Commandments

  --> whether euthanasia is murder or whether the text should be translated in terms of killing more generally may be a matter of debate

  -"the Lord gave, and the Lord has taken away; blessed be the name of the Lord' (Job 1:21)

  --> it is for God to decide the moment of birth & the moment of death; it cannot be a human decision as our lives are not our own but God's

  -"do you not know that your bodies are temples of the Holy Spirit, who is in you, whom you have received from God" (1 Corinthians 6.18)

  --> Paul in NT also reinforces idea that the believer's body in a sense belongs to God as the giver of life
• quality of life

  -some view quality of life as more significant than sanctity

  -quality of life principle takes the view that whether life is valuable depends on whether it is worth living; it needs to have certain characteristics in order to be valuable, e.g. happiness, autonomy or freedom from pain

  -Singer argues for replacing the traditional sanctity of life ethics with 5 quality of life commandments:

  --> 1) we should recognise the worth of human life varies

  --> 2) we should take responsibility for the consequences of our decisions to save or end life

  --> 3) we should respect a person's desire to live or die

  --> 4) we should only bring children into the world if they are wanted

  --> 5) we shouldn't discriminate on the basis of species

  -the ethical theory of S.E. typically favours quality of life over sanctity of life in dealing with issues like euthanasia
• the concept of sanctity of life is no longer useful strengths

  -upholds intrinsic value of life in culture where we increasingly dehumanise others

  --> BUT out of place in increasingly secular soc. ~>50% of people in UK don't believe in God & <10% regularly attend church

  -ensures basic rights respected, particularly where involved aren't able to speak for themselves

  --> BUT s.o.l at odds w/ people's autonomy in v. euthanasia

  -campaigners against euthanasia worry about slippery slope (pressure on vulnerable)

  -similar decline in respect for life when abortion legalised

  --> thought few 1000 cases each year on medical grounds, yet >180k each year UK

  --> BUT interpreting s.o.l as saving life at all costs self-defeating. People die in pain & aren't treated w/ dignity

  -BUT says all life must be saved at all costs. Given medical advances, now know better where treatment may not lead to improvement. Don't have to treat all people
• applying NL

  -NL ethics has 4 tiers of law, where the DL revealed by God is higher than the NL derived from reason

  -for Christians, the DL from the Bible appears to give clear guidance against the taking of life

  --> it is for God to bring life to an end, not humans

  -in Ecclesiastes Chapter 3, it states that there is "a time to be born and a time to die"

  -in terms of the NL, requirement to preserve innocent life is one of the 5 primary precepts

  -could logically lead to a secondary precept that would prohibit euthanasia

  -euthanasia itself could be thought of as an apparent good that would stand in contradiction of the real good of allowing life to continue its natural & God-given course
• applying NL continued

  -distinction can be drawn between ordinary & extraordinary means, which shows a possible secondary precept that could be drawn

  -obligation to give ordinary treatment such as food, yet no obligation to continue extraordinary treatment, which may mean that those who can't recover shouldn't be kept indefinitely on life-support machines

  -wouldn't be wrong for someone who is terminally ill to decline extraordinary treatment

  -Glover suggests 5+ options with regard to euthanasia:

  --> 1) take all possible steps to preserve life

  --> 2) take all ordinary steps to preserve life

  --> 3) not killing but taking no steps to preserve life

  --> 4) an act which has death as a possible foreseen consequence

  --> 5) deliberate act of killing

  -"discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate" ('Catechism of the Catholic Church')
• double effect and proportionalism

  -in 1999, Dr David Moor was cleared by a court of murdering a seriously ill 85yo cancer patient who had also had a heart attack & a stroke

  -a dose of morphine had hastened his death

  -Dr Moor said, "All I tried to do in treating Mr Liddell was to relieve his agony, distress & suffering... doctors who treat dying patients to relieve their pain & suffering walk a tightrope to achieve this"

  -double effect would support this decision

  -d.e. hinges on intention behind action

  -proportionalists go further & argue rules of NL can be broken if a proportionate reason to make an exception

  -proportionalists such as Maguire (1931-) argue in some cases where biological life continues but personhood greatly diminished, shortening process of dying is not in itself wrong

  --> approach condemned by RCs but not radically different from the idea of d.e., & issue of determining intention would also apply here
• NL doesn't provide a good approach to euthanasia strengths

  -NL committed to sanctity of life

  -NL avoids potential for a slippery slope to occur when life becomes increasingly less significant

  --> BUT overly religious & dependent on its Christian roots. Euthanasia was often practised in ancient world prior to dominance of Christianity. Euthanasia should be allowed now given we are an increasingly secular society

  -NL prevents individuals from playing God & making decisions about lives of others

  --> BUT can be legalistic & absolutist. Each person's situation is different, but NL insists on a common approach

  -idea of double effect provides some flexibility in rigid system

  -allows pain relief to continue despite frailty & vulnerability of patient

  --> BUT NL requires individuals to live when in extreme pain. Utilitarian would argue reduction of pain & focus on q.o.l would be better than NL approach
• NL doesn't provide a good approach to euthanasia strengths continued

  -in addition to rejection of quality of life, NL does not place sufficient weight on human autonomy

  --> this seems odd as surely the person concerned should be absolutely central to decisions about euthanasia

  -could be argued double effect may in some ways be euthanasia by default. It relies on us knowing the intention of the doctor. The distinction is not always easy to see between euthanasia, which NL rejects, and causing death as a secondary effect of pain relief
• applying S.E. to euthanasia

  -Fletcher supporter of euthanasia & served as president of Euthanasia Society of America

  -"it is harder to justify letting someone die a slow and ugly death, dehumanised, than it is to justify helping them escape from such misery" (Fletcher, 'Humanhood: Essays in biomedical ethics')

  -sanctity of life is not an absolute

  -S.E. rejects legalism in favour of asking what is the most loving thing to do

  -rules such as 'do not kill' are sophia (general rules of wisdom) but can be broken when love demands it

  --> s.o.l sophia

  -values q.o.l & autonomy over s.o.l

  -autonomy significant as 'personalism' is one of Fletcher's 4 principles; people & welfare rather than keeping of laws at heart

  -relativist - Fletcher states "love's decisions are made situationally, not prescriptively"

  -in 1954 book 'Morals and Medicine', argues patient's medical condition has to be starting point for any decisions in medical ethics
• Fletcher & Jim

  -Fletcher describes a chaplain's encounter with Jim, a terminally ill patient who is married with/ 5 children

  -the pills Jim takes, which may extend his life for 3 years, cost $40 every 3 days

  -Jim is quoted as saying: "The company has me insured for $100,000. It's the only insurance I have. It's all I can leave Betts and the kids. If I take the pills and live past next October, then the policy will be cancelled when it comes to renewal. If I don't take them, at least my family have some security. If I kill myself, they get even more. If I take the pills, borrow the money for them, and then the policy lapses, that will mean that they are going to be left penniless and in debt so that even the house goes. If I don't take the pills, I'm killing myself same as if I commit suicide"
• applying S.E. to euthanasia continued

  -Fletcher values pragmatism - we should do whatever is likely to work

  -in the topic of euthanasia there may not be ideal & perfect solutions, but what can be done is to ensure the decisions that are taken are likely to lead to the lesser of the possible evils

  -S.E. might suggest traditional religious ethics has come to the wrong conclusion on euthanasia as it has a mistaken rules-based view of what justice is

  -yet if justice is correctly understood, to end the life of someone in great pain who does not want to live any longer would not be unjust
• S.E. doesn't provide a good approach to euthanasia strengths

  -flexible

  --> offers general principles rather than fixed rules & allows us to respond to complex & varying situations

  --> BUT quite vague. Little guidance on what the most loving thing might look like in practice. May mean we differ as to what is most loving

  -agape good moral principle & puts people first

  --> clear improvement on utilitarian ideas of maximising happiness for majority

  --> BUT like other teleological theories, requires a prediction of future consequences. Not always possible in complex medical cases

  -modern tech. & medical knowledge means better placed to know who is/is not worth treating

  --> BUT lacks absolute boundaries & concern about a slippery slope that may lead to an increase in euthanasia cases, particularly for vulnerable people

  -respects autonomy of individuals & recognises patient is most significant person in situation
• case study 1-Daniel James


  -Daniel was a rugby player who played for England under-16s

  -during a training session in 2007, he broke his spine & was left paralysed from the chest down

  -difficult for him to adjust to needing parents & carers to help him do everything

  -having made several unsuccessful attempts to kill himself, his parents accompanied him to the Dignitas assisted-suicide clinic in Switzerland, where he died in 2008

  -his parents defended Daniel's decision, saying he was "an intelligent young man of sound mind" who was not prepared to live what he felt was a second-class existence
• case study 2-Hannah Jones


  -as a result of leukaemia & heart problems, Hannah had spent most of her life in & out of hospital

  -her cancer was in remission, but to stand any chance of survival she required a heart transplant, constant drug treatment & then a replacement transplant within ten years

  -at 13, Hannah decided she didn't want to go back into hospital & have the operation

  -she appeared on several TV programmes articulately justifying her decision and want to die

  -BUT she changed her mind, and decided to get the transplant. She achieved a 2:2 from university and says she "regrets nothing"
• autonomy and euthanasia

  -autonomy states humans should be free to make decisions about their own future

  -can be traced back to Mill's non-harm principle

  --> if we wish to harm ourselves, we should be permitted to do so

  -Singer's preference utilitarianism argues humans should be free to pursue their own desires & interests where possible

  -this autonomy includes right to make our own decisions about death

  -autonomy seems to be a key aspect in determining our own lives (we should have ability to determine time & manner of our own death)

  -linked to q.o.l & in cases of voluntary euthanasia is a judgement that someone makes about type of life they are living

  -Glover has suggested external checks are also required as to someone's state of mind, specifically that the decision is reasonable & not a temporary emotional state

  --> if someone is making the decision in a diminished mental state then they're not truly autonomous
• autonomy and euthanasia continued

  -issue of autonomy more complicated in non-voluntary euthanasia

  -if the patient has given instructions about what their wishes would be if they were in such a case then arguably their autonomy is being respected e.g. a DNR (do not resuscitate) notice, advance directives (living wills) where they state the circumstances under which they would want treatment to stop

  --> legally binding in event of someone losing capacity to make decisions about their own treatment

  -some opponents of euthanasia have expressed concern about such practices, and in 2011 it was found that some hospitals had been putting 'DNR' on the notes of frail elderly patients w/o proper discussion with the patient or their family
• people shouldn't have autonomy over their own lives & decisions strengths

  -S.E. supports autonomy

  -aspect of 'personalism' that we allow individuals to make decisions abt themselves

  --> BUT NL would reject view autonomy most important consideration. Life viewed as God-given & preservation of life a primary precept

  -many arguments against autonomy based on religious notion of s.o.l, which becomes irrelevant if God doesn't exist

  -autonomy more appropriate for a secular age

  --> BUT autonomy not supported by sacred texts like Bible. Specific commandments against taking of life, idea being time of birth & death appointed by God

  -BUT autonomy difficult concept to apply in traumatic times

  --> difficult for someone in agony to have clarity of thought to make good decisions abt end of their life

  --> in n-v cases, esp. involving vulnerable people, risk of decisions being made that aren't in person's best interests e.g. w/ DNRs
• acts and omissions

  -commonly held wisdom suggests an act that causes death is wrong, so active euthanasia, whether by lethal injection or by switching off a machine, is held to be wrong by those who oppose euthanasia

  -passive euthanasia, which involves omissions such as withdrawing a medical treatment or, as in the case of Tony Bland, a feeding tube, is often viewed as trickier

  -in these cases where it is clear that the patient will not recover, this may be viewed as simply allowing the person to die & this may not always be morally wrong
• acts and omissions challenge

  -James Rachels provides a thought experiment to suggest distinction between actively killing & passively letting someone die may not be helpful:

  --> case 1: Smith is legal guardian for his nephew & will inherit a fortune if his young nephew dies before his 18th birthday. He drowns the boy in the bath & arranges the scene to look like an accident. The nephew's death is an 'act' of Smith

  --> case 2: Same financial situation. Jones resents his nephew but would never intentionally harm him. As he enters the bathroom, he sees his nephew slip & hit his head on the bath & slowly drown. He watches and does nothing to save him. The nephew's death is an 'omission'; Jones could have saved him
• Rachels example analysed

  -commonly held view of acts & omissions says Smith is more guilty than Jones - an act is worse

  -yet Rachels disputes this

  -argues both are equally bad & when we consider the issue of euthanasia, a passive euthanasia that operates by omission may even be more cruel, as death may take longer

  -in Tony Bland case, the removal of the feeding tube meant that death didn't occur until 10 days later
• Singer on euthanasia

  -Singer has also challenged the distinction between acts & omissions by arguing that it is not always clear cut

  -removal of Tony Bland's feeding tube, or the turning of the dial that stops the nutrients, is in some senses an action even if the removal of food is an omission

  -not totally clear whether his death is an act or an omission
• ethical theories on acts and omissions

  -as with other absolutist & deontological theories, NL would draw a distinction between acts & omissions

  -key to theory is intention of agent who takes action

  -double effect may allow an act that leads to death, but this is only in the context of this being an unintended consequence (primary action to relieve pain)

  -as with other relativist and teleological theories, S.E. does not draw a great distinction between acts & omissions

  --> pragmatic in its approach

  -consequences are most significant aspect in ethics & outcome does not significantly change whether someone's life is ended by an action or by an omission

  --> their pain is relieved either way

  --> an act that leads to death may be quicker and kinder
• no significant differences between acts and omissions when it comes to euthanasia strengths

  -for NL thinkers, actions matter

  -preserving innocent life rules out acts directly leading to death, although idea of double effect allows some actions may lead to death

  --> BUT S.E. challenges distinction between acts & omissions. Are cases where agape requires the compassionate response of helping someone to end their life; whether this is by an act or an omission is not morally significant

  -distinction between acts & omissions takes seriously the issue of moral agency

  -if we were to allow active euthanasia, we would need doctors & other medical professionals to carry this out

  --> would conflict with Hippocratic Oath & cause anxieties for those physicians who are involved

  --> BUT a teleological approach that focuses on reducing pain & suffering would favour euthanasia by whichever method was most helpful in alleviating suffering
• no significant differences between acts and omissions when it comes to euthanasia strengths continued

  -one practical difficulty is that withdrawal of treatment is often a lengthy process & leads to medical resources being allocated to those who will not recover

  --> while it sounds harsh, allowing active euthanasia could speed up the inevitable process, thus freeing resources to focus on those who may recover

  -idea of double effect is complex & not entirely coherent

  --> if the negative consequence is foreseen then how can it truly be unintended?
• case study 3-Tony Bland


  -in 1989, Tony was critically injured in the Hillsborough Stadium disaster

  -left in a deep coma known as PVS, had very limited brain activity & had no prospect of recovering

  -doctors would not turn off his life-support machine as it was against the law & would break the Hippocratic Oath that doctors take to preserve life, meaning they would face prosecution for ending his life

  -Tony's parents went through various legal stages before the High Court ruled that Tony's treatment could be withdrawn

  -he died in 1993
• euthanasia

  -literally meaning a good death, it refers to the practice of hastening someone's death perhaps in order to spare them further suffering

  -illegal in UK (alongside assisted dying)
• assisted suicide

  A person who wishes to die is helped to die by another person. They may or may not have a serious or terminal illness.
• suicide

  A person makes a voluntary choice and takes their own life.
• Glover quote

  "I must be convinced that your decision is a serious one; it must be properly thought out, not merely the result of a temporary emotional state. I must also think your decision is a reasonable one" ('Causing Deaths and Saving Lives')
• Hippocratic Oath

  -Greek physician Hippocrates (460 - 370 BC) states wrong for doctor to do something that would cause death of person

  -however, in other writings, he suggests it is pointless to continue to treat those who are overcome by a disease & medicine is powerless

  --> distinction provides background for acts and omissions

  --> 'act' morally wrong, 'omission' not necessarily (generally)

  -"I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to that effect" ('HO')