PHIL 20602 David Solomon

End of Life Issues (I)

1) If a terminally ill patient in great pain asks his doctor to

help him end his life, the doctor is morally obligated to help. (3-237) (3-217)
2) If a terminally ill patient in great pain asks his doctor to

help him end his life, it would be morally permissible for the doctor to help. (72-168) (77-143)
3) If a terminally ill patient in great pain asks his doctor to

help him end his life, it would be morally wrong for the doctor to help. (103-137) (91-129)

End of Life Issues (II)

18) No effort should be made to prolong the life of a child

who suffers from a seriously incapacitating birth defect and where death is certain within a matter of months. (22-218) (14-206)
19) A doctor is never justified in ending the life of a

patient, but he may sometimes be justified in letting a patient die. (33-207) (105-115)
23) Physician-assisted suicide should be legalized.

(19-221) (32-188)

Abortion
6) A woman should have the right to have an

abortion at any stage of pregnancy.(21-219)(17-203)

7) Physicians should have the final word in

determining when abortions may be performed. (20-220) (36-184)

8) Abortions are morally wrong if performed after

the third month of pregnancy.(125-115)(128-92)

Truth-Telling in Medicine
4) There are circumstances in which it would be

morally permissible for your doctor to deceive you about the results of a physical examination. (63-177) (32-188)
5) Doctors should always tell their patients the truth.

(153-87) (144-76)

Medical Experimentation
12) It is morally permissible to create human embryos and

then destroy them to extract their stem cells for experimental purposes. (49-191) (34-166) children. (63-177) (73-147)

13) Medical experiments should never be performed on 14) Anyone who is a subject of a medical experiment should

have complete understanding of the risks involved. (204-36) (210-10) without his consent. (205-35) (167-53)

15) It is never permissible to experiment on someone

Justice and Health Care (I)

10) Everyone has a right to good medical care. (203-37)

(175-45)

11) Doctors make too much money. (38-202) (28-192) 17) If a medical procedure is too expensive to be made

equally available to everyone, it should not be made available to anyone.(116-124) (2-218)

20) Notre Dame women over 18 years of age should be

allowed to sell their eggs to the highest bidder.(92-148) (78-142)

Justice and Health Care (II)

21) The American health care system is the best in the

world. (14-226)

22) Patients like Mickey Mantle who destroy their

livers through long-term alcoholism should not be eligible for liver transplants. (33-207)

24) The state should insure that everyone has adequate

medical care. (175-65)

Paternalism
9) Certain religious sects forbid their members to have

blood transfusions. Doctors should respect the wishes of such persons in this regard even in life and death situations. (171-69) (147-73)

Definition of Disease
16) Alcoholism is a disease. (157-83) (131-89)

Foundations and Theory

Problems in Medical Ethics

Doctor < --------- > Patient
Confidentiality Truth-Telling Informed Consent Paternalism

Birth < --------- > Death

Reproductive technologies Abortion Seriously disabled infants Euthanasia Physician Assisted Suicide

Medicine < ----------- > Society

Allocation of scarce medical resources Organization of health care delivery system Regulation of medical professions

Common Mistakes in Thinking about Ethics

1) Problems of Deflection: transforming ethical problems into problems about:

Law Codes Custom Religious Practice Relativism Fatalism Particularism

2) Problems of Deflation

A Quick Analysis of Particularism

1) Strengths:
No two problems are the same 2) Rules are alienating come from outside 3) Rules are falsifying obscure detail
1)

2) Problems:
Importance of moral teaching 2) Need for reliable expectations 3) Only encounter problems as types 4) Moral problems presuppose rules.
1)

Structure of Human Action

Agent Action Consequences

Virtue Theories

Deontological Theories

Consequentialist Theories

Virtue Theories
Moral success = becoming a good person Most basic moral judgments are of persons Typically endorse a specific list of virtues (e.g., the

cardinal virtues, the theological virtues, the entrepreneurial virtues)

Notion of virtue is central May emphasize some picture of the ideal life for human

beings that is to guide us in coming to be a person of that sort.

Some Issues with Virtue Ethics

1) How can virtues tell us what to do?
2) Is there a best way for human beings to live? 3) Isnt the view too selfish?

Deontological Theories
Moral success = performing right actions Most basic moral judgments are of actions Typically endorse a specific set of rules (e.g., the

Decalogue) are central

Notions of obligation, rightness, wrongness, and duty Emphasize some fundamental moral principle that

applies directly to action (e.g., Kants Categorical Imperative: Act always in such a way that you can at the same time will the maxim of your action to be a universal law.)

Suggested Sources of Moral Rules

Intuition Universalizability Divine Commands

Consequentialist Theories
Moral success = bringing about as much good stuff

as possible

Most basic moral judgments are of consequences Typically endorse some list of good things to be

brought about by action (e.g., pleasure, happiness, desire satisfaction)

The Principle of Utility: Act always in such a way as to

bring about the greatest happiness for the greatest number

Notions of goodness and badness are central

A Consequentialist Matrix
Jones Act 1 4 Smith 4 Roberts 4 Sum 12

Act 2
Act 3

4
24

2
18

5
-9

11
33

Some Issues with Consequentialism

1) What is being measured? 2) Act vs. Rule Utilitarianism? 3) Taking the separateness of persons seriously

Munsons Taxonomy of Ethical Theories

1) Utilitarianism
2) Kants Ethics 3) Rosss Ethics 4) Rawls Theory of Justice

5) Natural Law Ethics and Moral Theology

6) Theories Without Principles (Virtue Ethics)

Principlism
James Childress and Tom Beauchamp, The Principles of

Biomedical Ethics
Autonomy Justice Beneficence Non-Maleficence

The Principles

Enormously Influential

Confidentiality, Truth-Telling, and the Doctor/ Patient Relationship

The Doctor/Patient Relationship

Complexity of this relationship History of this relationship Significance of the professional status of medicine Contemporary threats to this professional status

Why do we go to doctors?
To find out if we are healthy To find out what is wrong with us To fix what is wrong with us For a signature For assistance in getting/not getting pregnant To become stronger, taller, thinner, and/or more

attractive
And

Multiple Roles of Physician

Healer
Educator Gate-keeper Public Health Officer Scientist Beautician Comforter

Multiple Models of Patient/Physician Interaction

Active/Passive Guidance/Cooperation Mutual Decision Making Patient on Top

History of D/P Relationship (I)

The Traditional Period
Division between privileged and common physicians No clinical investigation Weak diagnostic powers Virtually no therapeutic success

History of D/P Relationship (II)

Modern Period
Revolution in clinical exam

Auscultation Percussion Palpation

New scientific basis for medicine

Pathological anatomy Germ theory of disease

Little therapeutic success Great prestige for physicians

History of D/P Relationship (III)

Post-Modern Period
Therapeutic success realized Less emphasis on treating patient as person Prestige of doctor decreases Medicine demystified

Medicine as a Profession
Traditional Professions Law Ministry Medicine Features of Professions Specialized knowledge Some commitment to service or altruism Self Regulation Personal identification with occupational role Special respect from clients or patients

Threats to Professional Status of Medicine

Government or social control of physician behavior Corporate or market interference in physician behavior Commodification of medicine

Patient Power movement

Medicine as a Profession
Traditional Professions Law Ministry Medicine Features of Professions Specialized knowledge Some commitment to service or altruism Self Regulation Personal identification with occupational role Special respect from clients or patients

Threats to Professional Status of Medicine

Government or social control of physician behavior Corporate or market interference in physician behavior Commodification of medicine

Patient Power movement

Why is Confidentiality So Important In Medicine?

Importance of Trust Importance of Full Disclosure Distinction between:
Broadly Consequentialist Considerations
Broadly Deontological Considerations

Obstacles to Preserving Confidentiality Today

Group medicine Electronic databases Physician decision making compromised

Prominence of liability considerations

Reasons for Compromising Confidentiality

The Patients Interest The Public Interest Institutional Obligation

Confidentiality and the Patients Interest: Tough Cases

Young girl with sexually transmitted disease Birth control case Elderly Golfer case

Why not let patients interest override confidentiality?

Physicians may not know their patients

overall best interest

Friends Family

General limits to paternalist interference

Distinction between:
Argument, advice, persuasion Manipulation

Confidentiality and the Public Interest: Tough Cases

Tarasoff case AIDS case Bus driver case

Should we always act to promote the public interest?

The Big Gain, Little Pain Principle But what about:
Special obligations? Promises Truth-telling Special relations? Family Friends

Confidentiality and Institutional Obligation: Tough Cases

Tough Cases: University Physician Industrial Physician Military Physician

All Cases Involve Conflict of Interest

Confidentiality and Conflict of Interest

Comparison between medicine and the law
Can conflict of interest be eliminated in medicine?
Incentives for physician referral and treatment Strength of professional standards For whom do physicians work? How special is medicine?

Solomons proposal: distinguish between:

Doctor Physician

Confidentiality and Conflict of Interest

Comparison between medicine and the law
Can conflict of interest be eliminated in medicine?
Incentives for physician referral and treatment Strength of professional standards For whom do physicians work? How special is medicine?

Solomons proposal: distinguish between:

Doctor Physician

Truth-Telling in Medicine
Contrast with confidentiality Recent changes in attitudes toward truth-telling Deep cultural differences in attitudes toward truth-

telling
Is Information Just Another Form of Therapy?

Forms of Deception in Medicine

Withholding Information
Terminal Diagnosis Alternative Therapies Physician Error

Deceptive Practices
Doctor Mislabeling Ghost Surgery

Lying
Placebo Therapy False Hope

Motives for Deception

To provide only usable information To increase patient confidence in a procedure To prevent psychological harm To increase the effectiveness of therapy To decrease patient anxiety

Changes in attitudes toward truth-telling (I)

Your patient has no more right to all the truth you know than he has to all the medicine in your saddlebags He should get only just so much as is good for him. Be very careful what names you let fall before your patient if he hears the word carcinoma, he will certainly look it out in a medical dictionary, if he does not interpret its dread significance on the instant. Tell him he has asthmatic symptoms You need not be so cautious in speaking of the health of rich and remote relatives, if he is in the line of succession. Oliver Wendell Holmes, 1871

Changing attitudes toward truth-telling (II)

1950s and 60s: overwhelming policy among doctors is

to withhold cancer diagnoses.

By late 70s, overwhelming policy among doctors is to

disclose cancer diagnoses.

Policy of disclosure remains dominant today.

Cultural Differences in Attitudes Toward Truth-telling

Outside the United States Traditional Confucian cultures Within the United States In a study African- and European-Americans tend to expect doctors to tell them the truth Korean- and Latino-Americans tend not to expect doctors to tell them the truth

Sissela Boks Three Arguments for Deception

It is impossible to tell the truth. Patients dont want to know the truth. The truth will be harmful to patients.

Why is Lying Wrong?

Two Kinds of Harm associated with Lying The Harm we do BY lying The Harm we do IN lying This distinction related to consequentialist vs. non-

consequentialist views of lying

The Harm we do BY Lying

Lying brings about false beliefs, and these are

harmful to persons.

But then the moral significance of the lie disappears

Lying brings about reduced trust among persons,

and that is harmful

What about lies told in secrecy? At the point of death On desert islands What about lies told when the truth is not expected? Poker Used car salesmen

The Harm We Do IN Lying

Some clichs about lying:
A lie involves defiling or degrading the liar. A lie is an insult to the person to whom it is told. A liar doesnt take the person to whom he lies seriously as

a person.

A lie involves treating the other person as a mere object. People have the right to know the truth.

Implicit in these clichs

The lie itself carries a weight of moral evaluation. Even in cases where the consequences of a lie are, on Even were it not the case that trust is important

balance, positive, there is something wrong with lying. among human beings, lying would be wrong.

Arguments for the claim that we do harm in lying

Intuitionist arguments Argument from moral personality

Argument from Moral Personality

Picture of Human Beings

Rational Capacities

Affective Capacities

Plans and Projects

Argument from Moral Personality

1. Rational creatures are an amalgam of Rational and Affective capacities that together determine our plans and projects. 2. It is a central part of being human that a persons plans or projects be his own. 3. A persons plans and projects are his own ONLY if they somehow grow out of the work of his rational capacities. 4. Respecting another person as a human requires treating him in a way that respects his rational capacities. 5. In lying, one does not show respect for the rational capacities of the other person. 6. In lying, one fails to respect the other person as a human.

Experimentation and Informed Consent

Medical Ethics

Basic Conflict in Human Experimentation

Social Benefit Individual risk

Compare to Problem of Staffing Military in War Time

Options Volunteer Army Mercenary Army Draft Army We ask a few to undergo risks for all of us

Why is it so difficult to recruit participants for experiments?

Eligible patients dont participate because
Its time-consuming Its risky It may require giving up the authority to choose own

treatment plan

Doctors dont refer eligible patients because

Its VERY time-consuming It can mean a loss of business They arent confident in the experiment

Controversial Instances of Medical Experimentation

Willowbrook experiments on hepatitis Tuskegee syphilis experiments Nazi medical experimentation Use of prisoners and other institutionalized subjects

Concept of Informed Consent (I)

Criteria for being informedrelevant information

about:
possible risks and benefits degree of pain and suffering experimental nature of the procedure purpose of experiment ability to withdraw

Concept of Informed Consent (II)

Requirements for giving consent:
sufficient maturity intellectual competence not emotionally unbalanced free from coercion

Problems with Informed Criteria

Who decides what is relevant? Sloan-Kettering Case How much information is enough? Lasagnas Law Is deception allowed? Friendly Female Strangers

What Constitutes Morally Objectionable Coercion ?

Use of children? Use of the sick? Use of the indigent? Use of addicts? Use of the institutionalized? Use of ones own patients?

How Do We Regard Information Gained in an Unethical Manner?

Two Examples: Nazi Case San Antonio Birth Control Case Can beneficial use redeem the evil?

US. Method for Obtaining Informed Consent (I)

1) Institutions required to have Institutional Review

Boards (IRBs)

2) Composition of IRBs at least five members some members not affiliated with home institution no conflict of interest not all members of same professional group

US. Method for Obtaining Informed Consent (II)

3) Investigators Submit: Experimental protocol Informed Consent Form 4) Committee has responsibility to: Approve or disapprove Keep appropriate records Oversee research

The U.S. Clinical Trial Process

Phase I

Small group of participants Tests for safety/ side effects

Phase II
Phase III Phase IV

Larger group More testing for safety/ side effects Looks for indications of effectiveness
Last phase before approval Large participant pool Tests for effectiveness (and safety) Follow-up testing of approved drugs Tests for long-term effects

Are there Groups That Should Never Be Experimented Upon?

Patients? Is the use of ones own patients intrinsically coercive? The Poor? Is paying the very poor for participation inherently exploitative? Prisoners? Can prisoners freely consent? Children? Can we consent for children?

Experimentation and the Poor (I)

The very poor are often recruited to participate in

Phase I (safety) tests of new drugs.

No health benefit expected for these participants. The available information on how these trials operate

suggests that most sponsors do not provide free care in the event of injury.
Monetary compensation can surpass that of a

minimum-wage job.

Experimentation and the Poor (II)

These individuals want to help society. Ill get a case of Miller and an escort girl and have sex.

T. Dwight McKinney, Executive Louis Checchia, study participant, Director of Clinical Pharmacology at on his plans for his earnings Eli Lily & Co., 1996, in response to questions about the companys use of homeless alcoholics in a Phase I trial

Arguments in Favor of Allowing Children to Participate in Medical Experiments

Children are required to obtain data in particular cases. Risks are lower with children in some cases. Proxy consent can be given by parents or guardians.

Argument Against Using Children

1) In the case of (a) pure and (b) non-trivial

experiments.

2) Proxy consent only seems justified in cases

where childrens best interest is at stake.

3) Parents or guardians are presumed to make

decisions based on the best interest of the children.

do not participate because it is in their best interest.

4) But in pure experiments, by definition, children

Abortion

The Abortion Storm (I)

Significance of Roe v. Wade (1973)
Revolutionary decision

unanticipated radical

Not preceded by significant public debate Substantive conclusions

trimester structure importance of privacy additions of Doe

The Abortion Storm (II)

Increasingly political nature of debate
Relation to more fundamental moral and political issues Mythic character of the debate
The Pro-Choice Myth The Pro-Life Myth

Lack of a middle-ground

Changes in U.S. Abortion Rate, 1973-2005

Abortion Rate*

Year
* Abortion rate = # of abortions per 1,000 15-44 year old women

Some Comments on Changes in U.S. Abortion Rate

From 1973 (Roe) to 1974, the abortion rate shot up 18%;

it increased another 12% the following year.

The abortion rate peaked in 1980-81, when it was 80%

higher than in 73.

Rate has fallen gradually since 81, but The current rate is still 19% higher than 73s rate.

How Prevalent is Abortion?

From 1973-2005, over 45 million abortions occurred in

the U.S.
In 2005, approx. 1.2 million abortions occurred in the

U.S.
It is estimated that, at current rates, 35% of U.S.

women will have had at least one abortion by the age of 45.

Who Has Abortions? (I)

In any given year, of women seeking abortions
86% are unmarried 60% have children 57% are in their 20s Over half (54%) were using contraceptives (often

imperfectly) the month they became pregnant.

Almost half (47%) have had a previous abortion.

Who Has Abortions? (II)

In any given year, the women seeking abortions are

disproportionately
Poor Black, Hispanic, or Asian From the Northeast or West

States with highest abortion rates*: New York (38.2) and New Jersey (34.3) Lowest: Wyoming (0.7) and Kentucky (4.4)
*abortion rate = # of abortions/year per 1000 women 15-44

Non-religious

Birth Histories of Women Having Abortions (at time of procedure)

Why do women have abortions?

When surveyed, most women give multiple reasons for

deciding to have an abortion, and these reasons are wide-ranging.

Yet two thirds of women cite one of the following three

reasons as their most important reason:

Not ready for a(nother) child / timing is wrong Cant afford baby now Have completed my childbearing / have other people depending on me 25% 23% 19%

Point in Pregnancy* at Which Abortions Occur

*calculated from last menstrual period

Just under 90% of abortions occur in the first trimester.

Abortion and Unintended Pregnancy (I)

Nationally, just under half (49%) of all pregnancies are

unintended.
Almost half (48%) of these end in abortion (excluding

miscarriages).

Abortion and Unintended Pregnancy (II)

When facing an unintended pregnancy More likely to abort Higher rates of unintended pregnancy Lower rates of unintended pregnancy
Unmarried Black

Less likely to abort

18-19 Poor (under the poverty line) High school degree or less Hispanic

Borderline: 20-29, lower middle class*

35 and older Middle class and above** Some college or more 15-17 Married White

Borderline: 30-34 *100-199% of poverty line *200% or more of poverty line

Abortion and Support Systems

If a woman is facing an unintended pregnancy, her chances

of aborting
Drop dramatically if she is married. Are significantly (22%) lower if she is 15-17 than if she is 20-

45. Are somewhat lower (11%) if she is cohabiting than if she is not (for single women).

A suggestion: The presence or absence of a strong social

support system plays a major role in how a woman responds to an unintended pregnancy.

Abortion, Screening, and Down Syndrome (DS)

An extensive study in the UK estimated that over 90%

of prenatal DS diagnoses result in abortion.

The estimate for the U.S. (albeit based on older and less

extensive studies) is 85%.

In 2007, the American College of Obstetricians and

Gynecologists recommended screening for all pregnant women (not just those 35+).

Complexity of Abortion Debate (I)

(1) Different Questions for agent physician medical auxiliary legislator (2) Nature of Consent womans spousal parental societal (3) Method of Abortion surgical saline chemical

Complexity of Abortion Debate (II)

(4) Auxiliary Conditions rape or incest age genetic difficulties economic hardship number of children (5) Age of Fetus within days of conception first trimester second trimester third trimester after birth

Some Philosophical Issues about Abortion

1) The Criteria of Personhood?
1) 2) 3)

Who is one of us? Distinction between persons and human beings Other problem areas Aliens The seriously disabled

2) Relevance of the concept of potentiality? 3) Resolving conflicts of rights? 4) The nature of the Right to Life?

Three Main Foundational Positions on the Morality of Abortion

Conservative View Liberal View Moderate View

Abortion: Conservative Strategy

1) Negative argument: Arbitrariness of any cut-off:
a) b) c) d) Viability Experience Quality of grief Social visibility

2) Positive arguments:
a) Increase in probabilities b) Presence of genetic code

Two Liberal Strategies

1) Exclusionary Strategies
Exclude the targeted population from the moral

community Similar structurally to traditional racist and sexist practices

2) Empowerment Strategies
Empowering some other group with regard to life and

death decisions about targeted population Similar structurally to some traditional liberationist practices

Abortion: One Type of Exclusionary Argument

1) The biological concept of a human being is distinct from the moral concept of a person. 2) The right to life attaches only to persons. 3) Being biologically human is neither necessary nor sufficient for being a person. 4) Rather, being a person is a matter of satisfying criteria XYZ. 5) A fetus never satisfies XYZ. 6) So, a fetus is not a person. 7) So, a fetus doesnt have a right to life. 8) So, abortion is morally permissible.

Warrens Criteria for Personhood

Consciousness Reasoning Self-motivated Activity Capacity to Communicate Self-awareness and Self- consciousness

A version of Michael Tooleys argument

1) One has a right to X, only if one is capable of desiring X. (by analysis of right) 2) One is capable of desiring X, only if one has the requisite concepts to desire. (analysis of desire) 3) To desire to continue living is to desire to continue existing as a subject of experience and other mental states. (analysis of the desire to live) 4) One is capable of desiring to continue existing as a subject of experience and other mental states only if one has the concepts of subject of experience, etc. (from 2, 3)

Tooley (Continuation)
5) Fetuses and infants lack the concepts of subject of experience, etc. (empirical observation) 6) Fetuses and infants are incapable of desiring to live (from 3, 4, and 5) 7) Fetuses and infants do not have a right to life. (from 1, 6)

Why Might Being Human Have Moral Significance?

1)

Centrality of Reciprocity to Morality. The Golden Rule Kants Categorical Imperative What if everybody did that?

2)

Some suggestions for determining who is one of us: We share a moral community with those in whose place we could be. We could be in the place of those who are essentially like us. Those who are essentially like us are other human beings. Tentative conclusion: Being a human being has special moral significance.

Indeterminacy and abortion (I)

Liberal Argument from Indeterminacy:
1)

We can only interfere with the liberty of others when there are clear and compelling rational grounds for believing that failing to interfere will cause significant harm to some person or thing we are charged to protect. Given indeterminacy, there are no such rational grounds in the abortion case. Given indeterminacy we must not interfere with the right of women to have an abortion.

2) 3)

Indeterminacy and abortion (II)

Conservative Argument from Indeterminacy:
1)

Given the moral gravity of killing the innocent, we can only allow abortions if we have clear and compelling rational grounds for believing that abortion is not the killing of creatures like us. Given indeterminacy, there are no such rational grounds in the abortion case. Given indeterminacy, we must not permit abortions.

2) 3)

Pascals Wager
Believe God Exists ~Believe God Exists

God Exists

~God Exists

God Exists

~God Exists

Abortion Wager
Believe fetus is a person ~Believe fetus is a person

Fetus is a person

~Fetus is a person

Fetus is a person

~Fetus is a person

Ethical Issues in the Treatment of Seriously Disabled Children

Some Difficult Cases

Downs Syndrome Spina Bifida Anencephalic Infants

Extremely Premature Infants

Moral Issues with the treatment of Seriously Disabled Children

1) Mode of treatment
a) b) c) d) Everything possible Ordinary treatment No treatment Direct Killing

2) Whose interests count?

a) b) c) d) Only the childs Childs and family Childs, family, society Future Children

3) How do we determine the interests of the severely disabled?

4) Who should decide?

a) b) c) d) Family Medical team Socially determined criteria Quasi-legal procedure

Lorbers criteria for withholding treatment in spina bifida cases

1) Gross paralysis of the legs 2) Thoracolumbar and thoracolumbosacral lesions. 3) Kyphosis or scoliosis 4) Grossly enlarged head 5) Intercerebral birth injury 6) Other gross congenital defects e.g., cyanotic heart disease, ectopia of the bladder, and mongolism.

Hides criteria for withholding treatment in spina bifida cases

1) 2) 3) 4) 5) Babys weight Size of head Degree of paralysis Presence of other abnormalities The health of the parents

Fletchers criteria for decision-making in cases of neonatal euthanasia

1) The extent to which parents are (or can be) counseled 2) Parents attitude toward the defects 3) Severity of the defect 4) Economic resources of the family 5) Welfare of other children involved, as well as the parents physical and emotional capacity to cope.

Euthanasia and Physician Assisted Suicide

Euthanasia and Assisted Suicide: Some Terminology (I)

Euthanasia = good death Broad definition: doing what will result in death, for the good of the person who will die
Narrow definition: intentionally killing a person, for the

good of that person

Active versus passive euthanasia

activekilling passiveletting die (withholding treatment)

Euthanasia and Assisted Suicide: Some Terminology (II)

Voluntary, involuntary, and non-voluntary euthanasia voluntary in accordance with the wishes of the recipient Involuntary against the wishes of the recipient non-voluntary recipient has no wishes

Assisted Suicide occurs when one person helps another person commit suicide (often by providing the means of death)

Medicine & the end of Life

Voluntary Involuntary Non-voluntary

ACTIVE

PASSIVE

Newsworthy Public Cases

Karen Ann Quinlan (In Re Quinlan, 1976) Nancy Cruzan (Cruzan v. Director, 1990) Elizabeth Bouvia Terri Schiavo

Dramatic Press Stories about More Active Physician Killing

Its All Over, Debbie Dr. Timothy Quill Dr. Jack Kevorkian The Netherlands Experiment in Euthanasia Bob Dent, Sept. 22, 1996 First Legal PAS in Oregon, March, 1998 Memorial Hospital, New Orleans, September, 2005

Legislative History
Washington, 1991 California, 1992 Oregon, 1994 (The Oregon Death with Dignity Act) Washington, 2008

Oregons Death with Dignity Act

Protects physicians and pharmacists from facing criminal,

civil, or professional penalties for prescribing or distributing lethal doses of medication in certain situations.
The patient must
Be an autonomous, informed adult.

Submit oral and written requests.

Undergo a waiting period. Have 6 months or less to live.

Good Faith provision protects doctors if some requirements

are (unbeknownst to doctor) not met

Top Reasons for Requesting Lethal Rx in Oregon (as reported by doctors)

Losing autonomy (89%) Decreased ability to participate in enjoyable activities

(87%)
Loss of Dignity (82%) Loss of control of bodily functions (58%) Burden on family and friends (39%) Inadequate pain control (27%) Financial Concerns (3%)

Disability Rights Objections to Legalizing Euthanasia and PAS (I)

Prejudice against disability is a primary motive for

legalization of euthanasia and PAS.

Legalization will disproportionately harm the disabled.
Suicide intervention compromised Familial and social pressure The problem of managed care

Disability Rights Objections to Legalizing Euthanasia and PAS (II)

Inadequate safeguards in actual legislation
Life expectancy prognoses unreliable Danger of doctor shopping Good faith provision gives doctors effective immunity

from negligence

Undue coercion and lack of effective choice will

undermine autonomy

More Recent Court Cases

9th Circuit: Compassion in Dying v. Washington, 1996 2nd Circuit: Quill v. Vacco, 1996 U. S. Supreme Court, June 1997

Differences in 1996 Rulings

9th Circuit Ruling: Liberty
Liberty interests in determining how ones life ends trump

any relevant state interests . Ban on PAS for terminally ill violates Due Process clause.

2nd Circuit Ruling: Equal Protection

If a competent, terminally ill person on life support has

a right to refuse treatment, a competent, terminally ill person not on life-support has a right to active assistance in dying.

Three Features of This Debate

Great Cultural Uncertainty A Big Deal A Surprising Time to have this Debate
Never been easier to die Never been easier to exercise control over death

The Killing/Letting Die Argument

1) There are no moral objections to letting patients die under certain conditions
Conditions History and current practice Religious teaching

2) There is no morally significant difference between killing and letting die at least in a wide range of cases.
Arbitrariness Inconsistency

3) Therefore, there are no moral objections to killing patients under certain conditions.

Autonomy argument
1) My life is my property. 2) I can do as I will with my property.
American argument Privacy argument in abortion debate.

3) I can do as I will with my life. 4) I can authorize my agents to carry out my wishes with regard to my life. 5) My agents can be justified in killing me.

Rachels Classic Arguments Against the Moral Significance of Killing and Letting Die
1) The Inconsistency Argument 2) The Arbitrariness Argument

Inconsistency Argument
1) Consider two terminal cancer patients
Smith, suffering to degree D, is respirator dependent 2) Jones, suffering to degree D, is not respirator dependent
1)

2) If we observe the distinction between K and LD,

we may be justified in allowing Smith to die (by removing the respirator), but not justified in killing Jones. 3) But the reason we feel justified in letting Smith die is to relieve his suffering. 4) But by observing the distinction between K and LD, we actually allow greater suffering for Jones. 5) And this seems inconsistent.

Arbitrariness Argument
1) Consider two Downs Syndrome infants:
1) Molly has DS with symptoms S plus a life threatening

condition. 2) Maggie has DS with symptoms identical to S, but no life threatening condition.

2) If we observe the distinction between K and LD,

we may be justified in allowing Molly to die, but not justified in killing Maggie.
life threatening condition.

3) But the reasons for letting Molly die are S, not the 4) The fact that Molly dies and Maggie lives in this

case seems objectionable and morally arbitrary.

Some Responses to the Killing/Letting Die Argument

1) They unfairly suppose that all letting die would be morally unobjectionable. 2) They overlook the volitional element in killing
-- Our ability to refrain from killing

3) Justice is more stringent than charity

Some Responses to the Autonomy Argument

1) Autonomy is not absolute Slavery Mill: Liberty cant be used to alienate liberty 2) Is my life really similar to my property? The Future Cone: Is death an event in life?

Present

Death

Two cases: Adolescent suicide Native Americans and their land

Double Effect
1) Action is not morally evil. 2) Bad effect is not means to a good effect. 3) Bad effect is not intended. 4) Good effect must be proportional to the bad effect.

Is the Distinction between Killing and Letting Die Morally Significant?

1) What is the distinction? 2) Should intention really matter? 3) Dont we intend everything that we foresee as the result of our actions? 4) The Problem of Closeness 5) Possibilities for moral blackmail
Jim and the Indians

The Gospel of Life (John Paul II, 1995)

Even when not motivated by a selfish refusal to be burdened with the life of someone who is suffering, euthanasia must be called a false mercy, and indeed a disturbing perversion of mercy. True compassion leads to sharing anothers pain; it does not kill the person whose suffering we cannot bear.

The Gospel of Life (John Paul II, 1995)

In reality, what might seem logical and humane, when looked at more closely is seen to be senseless and inhumane. Here we are faced with one of the more alarming symptoms of the culture of death, which is advancing above all in prosperous societies, marked by an attitude of excessive preoccupation with efficiency and which sees the growing number of elderly and disabled people as intolerable and too burdensome.

The Gospel of Life (John Paul II, 1995)

Taking into account these distinctions, in harmony with the Magisterium of my Predecessors [81] and in communion with the Bishops of the Catholic Church, I confirm that euthanasia is a grave violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person.

A Culture of Death
Theistic Concept of Human Life Dignity & worth of each individual Democratic forms of Government

Undercuts dignity
1) Unrestricted Freedom Legislation against Dignity

2) Relativism
3) Excessive Autonomy

Final Comments on Euthanasia

Doctors Shouldnt do the Killing Now is the Wrong Time to Legalize Euthanasia

What Can We Do?

Support Hospice Train Doctors Better in Pain Management Make Sure Advanced Directives are Respected

The Health Care Delivery System

Fixing American Health Care

The Crisis in the Health Care System Criteria for Evaluating Health Care Systems How we got into Present Crisis Where do we go now?

National Academy of Science Report on Health Care Crisis, 2003

The American health care system is confronting a

crisis. It is incapable of meeting the present, let alone the future, needs of the American public.

The cost of private health insurance is increasing

at an annual rate in excess of 12 percent. Individuals are paying more out of pocket and receiving fewer benefits. One in seven Americans is uninsured, and the number of uninsured is on the rise.

The Crisis in the Healthcare System

1) Cost
For Individuals For Society

2) Access
For the poor For everyone

3) Quality
Comparisons to other countries Infant mortality rate

Health Expenditures Per Capita: International Comparison

6000 5000 4000 3000 2000 1000 0 1960
United States

1970

1980
Canada

1990

1995

2000

2001

2002

2003

Germany

Source: Organization for Economic Cooperation and Development

France

United Kingdom

Consumer Price Index Comparison: 1986-2003

350 300 250 200 150 100 50 0 1986 1990 1995 2000 2001 2002 2003

Medical care

Food

Apparel

Housing

Energy

The cost of medical care has increased three-fold since 1986; no other category has increased even twice as much.

Health Expenditures as Percentage of GNP: International Comparison

16 14 12 10 8 6 4 2 0 1960 1970 1980 1990 1995
France

2000

2001

2002

2003

United States

Germany

Canada

United Kingdom

In 2002, the U.S. GNP was 10.4 Trillion; health expenditures totaled 1.5 Trillion.

Life Expectancy 2003

Infant Mortality 2001-2003

Three Philosophical Issues in Health Care Delivery

1) Right to Health Care 2) Equality of Health Care 3) Justice of the Health Care System

Criteria for Evaluating a Health Care System:

Justice Efficiency

Problems with Justice

1) Egalitarian vs. Merit-based view?
2) Egalitarian: What do we make equal?
1) Health outcomes? 2) Inputs? 3) Opportunities 4) QALYs?

3) Merit-Based: What constitutes medical merit?

1) Being a good citizen? 2) A healthy life style? 3) Being morally upright?

Problems with efficiency: What is measurable output?

1) Consumer satisfaction? 2) Consumer health? 3) Incidence of specific problems? 4) Morbidity and mortality rates?

Three Revolutions
1) Technological 2) Professionalization

3) Third party payer

Technological Revolution
The modern hospital 1907Medicine becomes worth it Effective Antibiotics Reasonable safety in abdominal surgery ICUs and CCUs Transplants and organ replacement Expansion of therapy

Psychological disorders Perfective procedures

Preventive Medicine

Professionalization Revolution
The Nineteenth Century: Real free market medicine

The chaos of medical education Doc and the Longhorn Saloon

Harvard, Johns Hopkins and the German model of medical education The Council of Medical Education (1904)

Promoted scientific medicine Proposed pre-med and med school standards

The Flexner Report (1910)

Licensure laws Locking up drugs

The ascendency of the AMA The physician as Captain of the Ship

Contraction of Med Schools after Flexner

Year 1904 Number of Med Schools 160 Number of Med Students 28,000

1920

85

13,800

1935

66

9,200

Third-Party Payer Revolution

1928Blue Cross invented in Dallas, Texas 1930s and 40sLabor unions push for health care

insurance
1965Medicare and Medicaid Currently: 85% of all physician bills paid by 3rd party payer 95% of all hospital bills paid by 3rd party payers

AMA Principles for Acceptable Private Insurance Plans (1934)

All features of medical service in any method of

medical practice should be under the control of the medical profession. the patient and his physician in any medical relation.

No third party must be permitted to come between

Patients must have absolute freedom to choose a

duly qualified doctor of medicine from among all those qualified to practice and who are willing to give service.

AMA Principles for Acceptable Private Insurance Plans (1934) (2)

A permanent, confidential relation between the

patient and a family physician must be the fundamental, dominating feature of any system.

All institutions involved in medical care are but

expansions of the equipment of the physician. The medical profession alone can determine the adequacy and character of such institutions.
formulated and enforced by the organized medical profession.

There should be no restrictions of treatment not

The Medical Triangle

Payment For Services

Government

Payers
Insurance Companies

Taxes and Premiums

Medical Care Providers Docs Hospitals You Patients Me

The Golden Age of Medicine

The 1960s were the golden age of medicine. Doctors could do anything they wanted to do and they could be confident that someone would pay for it.
Mark Siegler, M.D., University of Chicago

Strategies for Controlling the Triangle

1) Health Maintenance Organizations (HMOs) 2) Peer Review Organizations (PROs) 3) Diagnostically Related Groups (DRGs)

4) Wellness Programs
5) Quality Assessment Programs 6) Regional Rationing

David Mechanic: Good Things about Managed Care

Disciplines Practice Removes incentives for overmedicalization Tempers technological aggressiveness Restores the role of primary care physicians Potentially improves health maintenance and

preventative services

Improves patient education and communication

David Mechanic: Good Things about Managed Care (2)

Reduces administrative costs Facilitates peer review and practice standards

By cutting costs, may improve access for uninsured

Major Health Care Reform Proposals

Single Payer vs. Distributed Payer Single Tier vs. Two Tier Constrained Competition vs. Central Organization Capitation Payment vs. Piece Work Payment

Obama Health Care Plan

Requires Everyone to have Health Care Insurance Subsidizes those unable to afford insurance Mandated Package of Benefits Expands Medicaid Coverage Electronic Medical Records Wellness Programs Public Option? Abortion Coverage?

Future Dangers
Expanding Consumer Demand Expensive New Medical Technologies Aging Population Increasing Medicalization of Culture