Ending Life Medical Humanities IV Prof. Marija Definis-Gojanovic 2014-2015 Conceptual Issues SUICIDE (S) – involves one intending one’s death either as and end itself or as a means to some further end ASSISTED SUICIDE (AS) – involves someone helping another person commit suicide EUTHANASIA (E) – involves someone doing something to bring about someone else’s death (killing or letting die) with intention that the person die because the death is in the best interests of the person who will die TERMINATING TREATMENT Conceptual Issues Active (a) and passive (p) version aS – involves inducing death (e.g., by shooting) aAS – involves a doctor giving a patient something (e.g., death-inducing pills) aE – involves someone inducing death (e.g., injecting a death-causing drug) Passive versions may involve acts or omissions Conceptual Issues Distinction between: voluntary, nonvoluntary and involuntary V – willed by the party either killed or let die IV – against the will of the party killed or let die NV – killing or letting die takes place in the absence of there being a determination by the person killed or let die as to what he/she wills Distinction between: morally permissible, impermissible and dutiful Assisted suicide Committed with the aid of another person, sometimes a physician (term is often used with physicianassisted suicide (PAS) = involves a doctor "knowingly and intentionally providing a person with the knowledge or means or both required to commit suicide, including counseling about lethal doses of drugs, prescribing such lethal doses or supplying the drugs”.) Assisted suicide and euthanasia are sometimes combined under the umbrella term "assisted dying” (other euphemisms: "physician-assisted dying", "physician-assisted death", "aid in dying", "death with dignity", "dying with dignity", "right to die" "compassionate death", "compassionate dying", "end-of-life choice", and "medical assistance at the end of life”). Euthanasia Definitions • Euthanasia: the intentional killing by act or omission of a dependent human being for his or her alleged benefit. Not euthanasia unless death is intentionally caused. Thus, some medical actions sometimes labeled "passive euthanasia" are not euthanasia because intention to take life is lacking. Euthanasia: - Greek: “good death” - The modern concept of euthanasia came into being in the 20th century after the invention of life-extending technologies. These technologies help to save the lives of many people who suffer serious illness or injury. • Voluntary euthanasia: The person killed has requested to be killed. • Non-voluntary: When the person who is killed made no request and gave no consent. • Involuntary euthanasia: When the person who is killed made an expressed wish to the contrary. • Assisted suicide: Someone provides an individual with the information, guidance, and means to take his or her own life. • Euthanasia By Action: Intentionally causing a person's death by performing an action such as by giving a lethal injection. • Euthanasia By Omission: Intentionally causing death by not providing necessary and ordinary (usual and customary) care or food and water. Nazi Euthanasia Program (Action T4) The "euthanasia campaign" of mass murder gathered momentum on 14 January 1940 when the "handicapped" were killed with gas vans and killing centres, eventually leading to the deaths of 70,000 adult Germans. Professor Robert Jay Lifton, author of The Nazi Doctors and a leading authority on the T4 program: “The state must own death—must kill—in order to keep the social organism alive and healthy.” Dr. Jack Kevorkian • Assisted-suicide advocate, launched campaign for “right to die” • Tried for murder for his assists, convicted in 1999 • Saw euthanasia as “helping a suffering patient” • Believed laws limiting euthanasia, as well as limiting smoking, etc. • Died in June 2011 Pros and Cons PROS • It provides a way to relieve extreme pain • It provides a way of relief when a person's quality of life is low Pros and Cons PROS • Frees up medical funds to help other people • It is another case of freedom of choice Pros and Cons PROS • The right to life includes the right to die. • Death is the opposite of life, but the process of dying is part of life. Pros and Cons CONS • Euthanasia devalues human life • Euthanasia can become a means of health care cost containment • Doctors should not be involved in directly causing death Pros and Cons CONS • Mercy killing is morally incorrect and should be forbidden by law. • Is a homicide • Murdering another human cannot be rationalized under any circumstances Catholic Church's Perspective • Against Euthanasia • Believe that life is a gift from God • We are all made in God's image • Morally wrong o "Thou shall not kill" • The Catholic Church does not believe that people have a right to die. • Humans are free, but they cannot take their own lives. Catholic Church's Perspective • The Catholic Church does believe that it is morally acceptable to refuse extraordinary medical treatment. • Suicide is wrong o Assisting suicide is looked at the same way Two challenges to the double effect doctrine: euthanasia and abortion In these two situations killing is a method of treatment. It is strange that abortion is more widely permitted than euthanasia. A woman can choose to have her fetus killed but not herself. The euthanasia patient is already dying and requests death in his own interest. The doctor kills a healthy fetus in the interest of a third person. The paradox is partly explained by the lower value which society puts on prenatal—as opposed to postnatal—life. Cases involving the termination of life- extending treatment—or passive euthanasia Karen Ann Quinlan: In 1976, KAQ, a 22-year-old woman in a persistent vegetative state with no hope of recovery, was kept alive using a ventilator to sustain her breathing. Quinlan’s parents wanted to discontinue treatment but the hospital would not do so. The Supreme Court of New Jersey ultimately decided that the hospital could legally discontinue treatment for a patient like Quinlan in a persistent vegetative state – after first consulting with an ethics committee – without fear of criminal or civil retribution. Cases involving the termination of life- extending treatment—or passive euthanasia Nancy Cruzan: In 1983, 25-year-old NC was in a car crash that left her comatose. When Cruzan’s parents wanted to discontinue artificial nutrition and hydration several weeks after the crash, the hospital would not do so. The case went through the Missouri court system, and they received a ruling in their favor. They then requested removal of the artificial nutrition and hydration tubes, and, subsequently, Nancy Cruzan died. Cases involving the termination of life- extending treatment—or passive euthanasia Theresa Marie Schindler: Terri Schiavo case was a legal struggle involving prolonged life support in the United States that lasted from 1990 to 2005. The issue was whether to carry out the decision of the husband and legal guardian of Theresa Marie "Terri" Schiavo to remove Terri's feeding tube that provided life support. The case also spurred highly visible activism from the pro-life movement and disability rights groups. Ethical Issues Surrounding A range of different ethical and moral positions and arguments exist regarding active euthanasia: •Terminating life at the request of an individual is not immoral because it is the individual’s decision to make. •Terminating life may be justified in some circumstances if, and only if, there is compelling evidence that to continue living would be more harmful to the person than dying. •Terminating life is unethical in today’s society because there are not enough protections that would allow for a just and fair practice of euthanasia. •Terminating life is always unethical because it violates a) the moral belief that life should never be taken intentionally or b) the basic human right not to be killed. But there are groups and individuals who make moral distinctions between actively killing a person versus passively allowing a person to die. Supporters of the act of passive versus active euthanasia argue: •Physicians do not kill a patient by omitting treatment, but rather the disease takes the patient’s life. •Patients have a right to a “death with dignity.” Allowing a dignified death to occur naturally is a moral act, different from active euthanasia. Mercy killing (sometimes referred to as euthanasia) Is when someone directly ends another person’s life, because believe it is in their best interest in order to relieve pain and suffering from an incurable or terminal condition. Under the current law, anybody who ends the life of another can be charged with murder and would face mandatory life imprisonment if found guilty. Physician Assisted Suicide With physician assisted suicide, a doctor provides a patient with a prescription for drugs that a patient could use to end his or her life. The main distinction between physician assisted suicide and active euthanasia is that the doctor is not the person physically administering the drugs. In contrast to active euthanasia, where a physician would end a person’s life, assisted suicide is an active choice by a person to end his or her own life. For some people, physician assisted suicide seems a viable option that would allow the opportunity to forgo suffering and loss of control. The primary ethical arguments offered to justify physician assisted suicide are that it: - Allows autonomy and self-empowerment of the patient. - Shows compassion and mercy. - Gives freedom from suffering. • diagnosed with Amyotrophic Lateral Sclerosis (ALS) in 1991. (progressive, neurodegenerative disease - causes weakening of muscles and eventual atrophy (wasting away) of body parts. ) • advocate of the legal right to assisted suicide and “dying with dignity”. Went before the Supreme Court of Canada twice to fight for her cause: the legal right to assisted suicide. • progression of physical disability and deterioration until death in 1994. (3 years after diagnosis.) 1. • Dr Nigel Leigh Cox (born 1945 in Surrey is an English consultant rheumatologist and one of the few doctors in Britain to have been charged with attempted murder. In 1992 he was convicted of the attempted murder of patient Lillian Boyes, and received a suspended sentence. 1. Reasons for opposing assisted suicide Medical ethics Hippocratic Oath Physician-assisted suicide is contrary to the original Hippocratic Oath that has been in use since the 5th Century BC, stating "I will give no deadly medicine to anyone if asked, nor suggest any such counsel". The Declaration of Geneva The a revision of the Hippocratic Oath, first drafted in 1948 by the WMA in response to euthanasia, eugenics and other medical crimes performed in Nazi Germany. It contains, "I will maintain the utmost respect for human life.” Reasons for opposing assisted suicide Medical ethics The International Code of Medical last revised in 2006, includes "A physician shall always bear in mind the obligation to respect human life" in the section "Duties of physicians to patients”. The Statement of Marbella was adopted by the 43rd WMA Malta and editorially revised by the 44th WMA in Marbella, Spain in 1992. It outlines guidelines for physicians when dealing with hunger strikers. Physician-assisted suicide is not explicitly prohibited, but is contrary to the principles of this statement. Legality Euthanasia is legal in Belgium, the Netherlands and Luxembourg. Assisted suicide, where the patient has to take the final action themselves (unlike euthanasia), is legal in the Netherlands, Luxembourg and Switzerland. In the United States there are assisted dying laws restricted to terminally ill and mentally competent adults in Oregon, Montana, Washington and Vermont. Oregon was the first US State to legalize assisted suicide, which was achieved through popular vote. Legality by country Australia Assisted suicide is currently illegal throughout Australia, but was for a time legal in the Northern Territory under the Rights of the Terminally Ill Act 1995. Belgium The "Euthanasia Act" legalized euthanasia in Belgium in 2002, but it didn't cover assisted suicide. In 2006, Belgium legalized partial euthanasia with certain regulations. Legality by country Canada Suicide was considered a criminal offence in Canada until 1972, after which it was removed from the Criminal Code. Physician-assisted suicide is considered illegal. In June 2014, doctor-assisted suicide or euthanasia became legal in the province of Quebec. Denmark Denmark has no laws permitting assisted suicide. Assisted suicide is illegal and punishable as manslaughter by up to 3 years. Legality by country France The controversy over legalizing euthanasia and physician assisted suicide is not as big as in the United States because of the country's "well developed hospice care programme”. In 2013 President Francois Hollande said that France should hold a national debate on the issue and stated his intention to introduce a bill to parliament before the end of the year. Opinion polls in France show that the majority of the public are in favour of an assisted suicide law, however France's national ethics committee has advised against any change in the law. Living will A living will usually provides specific directives about the course of treatment that is to be followed by health care providers and caregivers. In some cases a living will may forbid the use of various kinds of burdensome medical treatment. It may also be used to express wishes about the use or foregoing of food and water, if supplied via tubes or other medical devices. In the Netherlands, patients and potential patients can specify the circumstances under which they would want euthanasia - by providing a written euthanasia directive. Hospice Hospice care is a type of care and philosophy of care that focuses on the palliation of chronically ill, terminally ill or seriously ill patient's pain and symptoms, and attending to their emotional and spiritual needs. In Western society, the concept of hospice has been evolving in Europe since the 11th century. The modern concept of hospice includes palliative care for the incurably ill given in such institutions as hospitals or nursing homes, but also care provided to those who would rather spend their last months and days of life in their own homes. Palliative care Palliative care is a multidisciplinary approach to specialised medical care for people with serious illnesses. It focuses on providing patients with relief from the symptoms, pain, physical stress, and mental stress of a serious illness—whatever the diagnosis. The goal of such therapy is to improve quality of life for both the patient and the family. Palliative care is provided by a team of physicians, nurses, and other health professionals who work together with the primary care physician and referred specialists to provide an extra layer of support.