Advance Directives: Social and Ethical Implications

Ethical Issues of Life and
Chan Ho Mun, Ph.D.
Associate Professor of Philosophy
Department of Public and Social Administration
City University of Hong Kong
June 22, 2006
• Abortion
• Suicide
• Euthanasia
• Physician Assisted Suicide
• Advance refusal of treatments (Advance
• Top-down approach: You start with a
defense of some principles or abstract
ideas, and then apply them to analyze an
ethical issue.
• Bottom-up approach: Compare like with
like or identify the difference among cases.
• A Combined approach
• Critical thinking is essential
Top-down Approach
• A principle-based argument against
– Fetuses are members of the human species.
All human are of equal moral worth and have
the equal right to live. So abortion is morally
• Objection
– Why should we count fetuses as humans? The
major premise of pro-choice argument is that
fetuses are not humans. So they do not
possess the right to life.
• Both sides accept the sanctity of human
lives, but the issue cannot be resolved
solely by appealing to this principle.
Bottom-up Approach
• A defense of abortion:
– Thomson’s People-seeds argument: Imagine
that people-seeds can drift in the air like
pollen and take root in your carpet or
upholstery. The person-plant does not have a
right to the use of your house though you
voluntarily open windows, knowingly keep
carpet and upholstered furniture, and your
window screens have defects.
• An argument against abortion (Marquis):
– Killing someone is morally wrong because it
causes her premature death. It deprives her
of a “future like ours” (FLO)
– Abortion is similar to killing someone in the
sense that it deprives the fetus’ of an FLO. So
it is morally wrong.
The Importance of Critical
• Principles can be inconsistent, and
resolution is needed when conflicts arise.
• Arguments from analogy are defeasible:
Though the similarity between two cases
can lead support to a certain conclusion,
their difference may undermine the
strengthen of the analogy.
Three Guiding Moral Principles
• Principle of the sanctity of life: Life itself
has intrinsic value in the sense that the
mere existence of a life in itself has a
value that is independent of its quality.
• Principle of autonomy: People have the
right to choose how they want to live their
livies instead of being forced to subject to
the will of others.
• The welfare principle: Human actions
should always seek to promote human
interests and well-being, and should
always try to reduce pain and sufferings.
The Crux of the Problem
• The three principles are not necessarily
consistent. How to resolve the tension
among them when conflicts arise?
• Four approaches:
– Euthanasia
– Physician assisted suicide
– Pro-life approach
– Advance directives
• Euthanasia can be defined as a deliberate
attempt undertaken by a physician to
relieve the pain and suffering of a patient
by killing him/her or terminating his/her
life intentionally.
• Supporters of euthanasia believe that the
intrinsic value of life can be overridden by
the principle of autonomy and the welfare
Voluntary, Involuntary, and Nonvoluntary Euthanasia
• Voluntary euthanasia: The patient chooses
• Involuntary euthanasia: It is offered
against the wish of the patient.
• Non-voluntary euthanasia: It is offered to
the patient who has not expressed his/her
prior preference before s/he loses the
decisional capacity or is never able to
make such an expression.
Active and Passive Euthanasia
• Active euthanasia: An active measure,
such a lethal injection, is used to
terminate the life of a patient.
• Passive euthanasia: A deliberate attempt
of not saving the life of a patient.
• Is the moral difference between active and
passive euthanasia significant?
• James Rachels: They either stand or fall
Physician Assisted Suicide (PAS)
• The justification is the same as euthanasia.
• The doctor involved cannot be said to
have killed the patient.
Utilitarian Argument Against
Euthanasia and PAS
• Whose welfare? Social or individual?
• Some people may feel being pressured to
choose euthanasia or PAS.
• Non-voluntary or even involuntary
euthanasia will become more widespread.
• Palliative care and hospice services will
become less developed.
• Less incentive to invent or develop more
effective treatment for the terminally ill.
A Pro-life Approach
• The intrinsic value of life is absolute. It
can override the principle of autonomy
and the welfare principle.
• The health care profession is obliged to
fight death to the very end.
• Withdrawing/withholding life-sustaining
treatment is morally wrong if the life of a
patient can be prolonged.
• Suicide is morally wrong and should even
be regarded as a criminal offence.
Suicide: Do we have a right to
• It is not a criminal offence. It was
decriminalized years ago, so strictly
speaking, people do have some liberty to
terminate their own lives.
• Yet they do not have to right to do so.
Aiding and better of suicide are regarded
as criminal offences. Trying to stop
someone to kill him/herself does not
constitute a violation of his/her basic
• Suicide is moral permissible, desirable, or
even obligatory in some special
circumstances in the East Asian cultures.
Yet the rationale cannot be used to justify
physical assisted suicide.
• So is the intrinsic value of life absolute?
Advance Refusal of Treatments
• Providing treatment to a patient without
consent can be regarded as an assault or
battery of the patient.
• Patients have the right to
contemporaneous refusal of treatment
when they are mentally competent.
• Patients can use advance directives to
express their advance refusal of treatment
before they lose their decisional capacity.
• This approach tries to pay due respect to
all the three guiding moral principles.
Is It a Form of Euthanasia?
• No.
• Argument from Autonomy: The attending
healthcare team just follows the wish of
the patient.
• Argument from Intentionality: The
attending healthcare team has no
intention to kill the patient or hasten
his/her death.
• Argument from Futility: If the refused
treatments could only prolong the dying
process and their burdens outweigh their
benefits, they are regarded as medically
futile and the attending healthcare team
does not have an obligation to provide
Is It a Violation of the Principle
of the Sanctity of Life?
• Not saving the life of a drowning person if
you are in a position or obliged to do so is
morally wrong.
• Yet if a patient is dying, withholding or
terminating treatments that would only
prolong the dying process does not
amount to not saving the patient or
hastening his/her death.
• The provision of life-sustaining treatment
to a dying patient may only prolong the
dying process, but saving a drowning
person will not have this consequence.
• Chan, Ho Mun, “Euthanasia: Can Life Become not
Worth Living”, in Julia Tao and Hektor H T Yan (eds),
Meaning of life. Singapore: McGraw Hill Education,
2006, pp.263-282
Chan, Ho Mun, “Sharing Death and Dying: Advance
Directives, Autonomy and the Family” Bioethics, Vol.
18, No. 2, 2004, pp.87-103.
Chan, Ho Mun, “Informed Consent Hong Kong Style:
An Instance of Moderate Familism”, Journal of
Medicine and Philosophy, Vol. 29, No. 2, 2004,
• Chan, Ho Mun, “Euthanasia, Individual Choice and
the Family: A Hong Kong Perspective”, in H. T.
Engelhardt, Jr. and L. M. Rasmussen (eds.), Bioethics
and Moral Content: National Traditions of Health
Care Morality, Dordrecht, Netherlands: Kluwer
Academic Publishers, 2002, pp. 165-190.
陳浩文 “末期病人的決策倫理:三個模式的比
較”, 《中外醫學哲學》III:4 (2001年12月):頁
陳浩文、高永文 “安樂死的謬誤、病人自決權與
• Marquis, Don, “An Argument that Abortion is
Wrong”, in Hugh LaFollette (ed.) Ethics in Practice:
An Anthology, Oxford: Blackwell, 2002, pp. 83-93.
Rachels, James, “Active and Passive Euthanasia”, in
Helga Kuhse and Peter Singer (eds.), Bioethics,
Oxford: Blackwell, 1999, pp. 227-230.
Thomson, Judith Javis, “A Defense of Abortion”, in
Hugh LaFollette (ed.) Ethics in Practice: An
Anthology, Oxford: Blackwell, 2002, pp. 63-71.