Ethics in Practice – Case Study Analysis
Isobel Stevenson
Peter, a 32 year old, suffered horrific injuries as the result of the collapse of a bridge
over which he was driving his car. He has been classified as being in a persistent
vegetative state for the past five years.
Although Peter’s brain stem is still
functioning, his heart is beating and he can breathe spontaneously, he is dependent
on oral feeding for the continuation of his life. The doctors in charge of his case have
come to the decision that Peter’s life is no longer of value to him and have requested
that they be allowed to withdraw his food supply. It is legal for doctors to withdraw
medical support, however, feeding a patient is regarded as part of palliative care and
not a medical treatment. Peter’s parents have taken the case to court in order to
prevent his doctors from withdrawing his feeding tubes. What decision would you
advise the judges to make in this case?
The debate over whether to withdraw Peter’s food supply in the above case arises
from the conflicting values of his parents and his doctors. Peter’s perspective is
central to evaluating the case; the withdrawal of his feeding tubes violates his right to
life. The constraint of Peter’s role is that being in a persistent vegetative state, he is
unable to exercise his autonomy and indicate what value he believes should be placed
on his life.
As Peter is unable to express his judgement, and we don’t know if he has expressed
an opinion prior to this event, his parents take on the role of representing his interests.
His parents are required to use their knowledge of Peter’s values to decide his best
interests1. Their decision that Peter’s life should be prolonged can be argued for using
Utilitarianism, Deontology, and virtue ethics.
In a general sense, Utilitarianism
prevents the ending of human life if so doing fails to optimise the goods the position
holds to be valuable. If one takes Peter’s loved ones to be the applicable society, and
the valued goods to be continuation of hope, or prevention of grief, then such a moral
1
Brock, Dan W., ‘Life-Sustaining Treatment and Euthanasia: Ethical Aspects’, in
Stephen G. Post (ed.), Encyclopedia of Bioethics, 3rd ed. (New York: Macmillan
Reference, 2004), Vol. 3, p. 1412
1
theory would prohibit the withdrawal of his feeding tubes. In terms of Aristotelian
ethics, the determination to sustain Peter’s life entails virtues of courage, loyalty and
caring, thus this moral theory can support his parents’ decision.
Morality as right acts and intentions can also support this decision. Deontology leads
to a fundamental moral duty not to deliberately end an innocent human’s life, a duty
to respect the intrinsic value of human life. This duty follows from Kant’s practical
imperative that humans must always be treated as means in themselves, never as ends
alone. The intrinsic value of human life is also supported by the concept that a right
to life is the foundation of all other rights. Rights and duties are complementary
within deontology as our being dutiful upholds the rights of others, and our rights
result from others’ performance of their duty. Humans have a right not to be killed,
as so doing denies them their future. Peter’s parents’ decision upholds their duty to
respect the intrinsic value of human life, and upholds Peter’s right not to be killed.
The stance the Peter’s parents take can be defended by all of the moral theories
outlined, especially if we know that Peter is not in pain.
The position that Peter’s doctors have taken on can also be argued for through all of
these moral theories. His doctors are able to draw on their experience as well as their
knowledge and training to assess Peter’s case. Their perspective is in keeping with
Aristotelian ethics as the virtues of judgement and resoluteness are employed.
Importantly, his doctors use phronesis, practical wisdom, which is a central value in
Aristotle’s account2. The perspective of Peter’s doctors may be related to deontology
in that it involves a sense of duty, universalisabilty. However, Deontology is a much
more effective framework for supporting Euthanasia when consent is given by the
patient, as the individual’s right not to be killed could then be understood as waived3.
In a teleological framework, Euthanasia can be defended as it brings an end to the
pain and suffering of the patient, which is surely a meaningful consequence. It is
2
Jonsen, Albert R. and Stephen Toulmin, ‘Theory and Practice’, in The Abuse of
Casuistry: A History of Moral Reasoning (Berkeley: University of California Press,
1988), pp. 23-45.
3
Brock, Dan W., ‘Life-Sustaining Treatment and Euthanasia: Ethical Aspects’, in
Stephen G. Post (ed.), Encyclopedia of Bioethics, 3rd ed. (New York: Macmillan
Reference, 2004), Vol. 3, p. 1413
2
unclear in Peter’s case whether or not he feels pain, and perhaps it is not possible to
ascertain what someone in a persistent vegetative state is aware of. Utilitarianism
demands Euthanasia in cases where it would produce the greatest balance of benefits
over harms. It is entirely plausible for this to be the case with Peter. The ending of
his life would free up resources which could be of benefit for other patients. He may
be used as an organ donor which would again benefit other patients. The ending of
his life may even ultimately benefit his parents, since by being forced to let go they
will be forced to confront their grief. If these consequences hold as optimal, Peter’s
doctors’ decision is supported by Utilitarianism.
The best possible ethical response to Peter’s case depends on what values are given
most weight, which moral theory is accepted. His parents’ position is supported most
strongly by deontology, whereas his doctors’ decision is more in keeping with
Aristotelian ethics.
The moral framework I found most convincing is that proposed by Carol Gilligan
whereby a care perspective exists in addition to the traditional justice perspective. The
central concerns of an ethic of care are sensitivity to others needs, responsibility for
taking care, and maintaining relationships. From a care perspective, relationships are
organized in terms of attachment, as a network or web, whereas from a justice
perspective relationships are organized in a hierarchy in order to look at equality. In a
care perspective the relationship is the figure, the moral agent, whereas in a justice
perspective the self is the moral agent who judges conflicting claims against a
standard of equality4. The ultimate end of the care ethic is maintaining relationships.
The end of the justice model is personal liberty. Gilligan proposes that one can see a
moral problem from one perspective initially, but when guided view it from the other
perspective, however individuals generally have a preferred or dominant way of
viewing a moral dilemma. Gilligan emphasizes that care and justice perspectives are
not polar opposites, or mirror images, they are different ways of looking at the basic
elements of moral judgment. The fact that they are not polar opposites, with one
perspective a better or worse way of passing moral judgment is, according to Gilligan,
4
Gilligan, Carol, ‘Moral Orientation and Moral Development’, in Eva Feder Kittay
and Diana T. Meyers, eds, Women and Moral Theory (Totowa, NJ: Rowman &
Littlefield, 1987), pp. 22-23
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what makes seeing both perspectives so difficult, the terms of one perspective do not
define the terms of the other.
Gilligan’s theory is appropriate to consider here for two reasons. Firstly the other
moral theories have been criticised within the Euthanasia debate for being overly
calculative, inadequate to express the complexities involved in end of life decisions.
Secondly, the care perspective contains important insights for this case as ultimately it
seems less about Peter’s concerns in and of themselves, than it is an issue about
Peter’s parents, and their connectedness with their son’s body. An ethic of care can
account for this in way that other moral theories can’t. Through this theory it would
seem morally wrong to forcefully remove Peter from his parents, yet it also seems
unethical to allow his parents to define the remainder of their lives around the
motionless form that remains of their son.
The best possible ethical response to this case is not to end Peter’s life against the will
of his parents, nor is it to leave him dependent on a feeding tube indefinitely. Ideally
a situation would be created where his parents made the decision to end Peter’s life. I
would advise the judge to recommend counselling for his parents, to enable them to
address their grief, and come to a place where they are able to let go of Peter’s
physical form. When this occurs, the greatest balance of benefits over harms would
clearly be to end Peter’s life, so this outcome would be demanded by utilitarianism.
Peter’s doctors and parents would be demonstrating virtues of judgement,
resoluteness, courage and caring. Their decision would be reached through phronesis,
and thus supported by Aristotelian ethics5. His parents’ consent would waive Peter’s
right not to be killed, and hence the ending of his life would not be in sharp contrast
with the values of deontology. Peter’s parents’ relationship with his memory would
be preserved, so achieving the ultimate end of an ethic of care. This decision would
therefore satisfy the conditions of each moral theory examined.
The ethical response I have given depends on the assumption that Peter’s life is no
longer of intrinsic value to him, as claimed by his doctors. If it was known that Peter
5
Aristotle, selections from Nicomachean Ethics, in The Ethics of Aristotle: The
Nicomachean Ethics, trans. J.A.K. Thomson. rev. Hugh Tredennick (Harmondsworth:
Penguin Books, 1976)
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was aware of pain, then I would form an argument for ending his life regardless of his
parents consent. If it could be shown that Peter was aware of what was going on
around him, but was not in pain, this would again alter my decision. The implications
of being aware but unable to respond would need to be considered.
The other
particular given in the case, which initially seems to differentiate it from a general
debate about euthanasia of incompetent patients, is that Peter is receiving palliative
care rather than medical treatment. This affects whether his treatment is understood
as ordinary or extraordinary, but this distinction doesn’t seem to affect whether the
continuation or withdrawal of care is morally obligatory6.
The decision I have advised in this case seems to be the best possible ethical response,
but it is unknown whether it would be successful in practice. The response assumes
that Peter’s parents are adamant that his palliative care continues because they feel
connected to their son by his physical presence, and are enabled by the continuation
of his life to foster hope. It is possible that his parents object to ending his life for
other reasons, such as religious beliefs. If this were the case I still believe a strong
attempt to convince Peter’s parents to consent must precede the involuntary ending of
Peter’s life if such an action is to be ethically defensible.
6
Brock, Dan W., ‘Life-Sustaining Treatment and Euthanasia: Ethical Aspects’, in
Stephen G. Post (ed.), Encyclopedia of Bioethics, 3rd ed. (New York: Macmillan
Reference, 2004), Vol. 3, p. 1412
5
Bibliography
Aristotle, selections from Nicomachean Ethics, in The Ethics of Aristotle: The
Nicomachean Ethics, trans. J.A.K. Thomson. rev. Hugh Tredennick (Harmondsworth:
Penguin Books, 1976)
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Stephen G. Post (ed.), Encyclopedia of Bioethics, 3rd ed. (New York: Macmillan
Reference, 2004), Vol. 3, pp. 1410-20.
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Diana T. Meyers, eds, Women and Moral Theory (Totowa, NJ: Rowman & Littlefield,
1987), pp. 19-32
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1988), pp. 23-45.
Norden, Margaret ‘”Whose Life is it Anyway?” A Study in Respect for Autonomy’,
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