On April 14, 1975 a twenty one year-old New Jersey teenager was rushed to Newton Memorial Hospital after collapsing at a party she was attending with friends that evening. She was admitted to Newton Memorial in a state of coma, unable to breathe for herself. After remaining in an unresponsive state for over nine days, she was transferred to a larger facility at Saint Clare’s Hospital in Denville, NJ. It was later learned that the girl had in fact consumed gin and tonics at the party after withholding food in order to lose weight for over two days.
The person being referred to in this case is Karen Ann Quinlan, one of the first significant US case in the “right to die” debate. Quinlan had suffered irreversible brain damage as a result of extended respiratory failure of about 15-20 minutes. Doctors hypothesized that Quinlan had passed out from the alcohol on an empty stomach and consequentially aspirated on her own vomit. Quinlan’s eyes were observed to be disconjugate and her electroencephalography (EEG) showed abnormally slow wave activity. Medically, Quinlan displayed what has come be known as a persistent vegetative state, or PVS.
As the Quinlan case goes, her condition only worsened with time as she became dependent on nasogastric feeding and a constant breathing ventilator. She continued to lose weight and remained in a highly unstable condition for months. In 1976, the Quinlan family decided not to keep Karen on life support since her condition seemed to be beyond recovery. The hospital refused to remove the feeding tube and the family took the case to the New Jersey Supreme Court. On March 31, 1976, the Court decided in favor of Quinlan and instructed the hospital to remove the ventilator. To everyones surprise, Karen Ann Quinlan remained alive with only the aid of artificial feeding for about nine more years until her eventual death of pneumonia on June 11, 1985.
Karen Ann Quinlan’s case was groundbreaking and set the initial precedent for similar “right to die” cases. The Quinlan case continues to raise interesting debate in moral theology, bioethics, euthanasia, legal guardianship, and civil rights. Three tangible consequences of the Quinlan case was the institution of formal ethics committees in hospitals, the establishment of nursing homes and hospices, the establishment of health care proxies, and the development of advance heath directives.
Though the case broadly encompasses many fields of thought and theory, the case remains the focal point for the death with dignity, “right to die” movement. Dying today has become a great deal more complicated than it had been a century ago. Rather than allowing natural death take its course, many medical and technological advances have allowed individuals to prolong their lives and stave off death for as long as possible. For many, this is a great thing because extending life is of great importance to them, but for other more terminally ill patients, staving off death may not be in their best interest. Matter of fact, the great debate lies in this incidental conflict of interest between the personal considerations of the patient and the medical and legal consideration of those providing the care. Court rulings have clearly affirmed a patient’s legal right to discontinue life-sustaining treatment at their choosing. In addition, there is extensive precedent for allowing family members to act as health care proxies on behalf of patients incapacitated beyond normal consciousness. However the unresolved section of debate remains whether a physician has the right to hasten a patients death if those are in fact the wishes expressed by or on behalf of the patient. This is of course referring to euthanasia or physician-assisted suicide.
End of life issues such as these pose some fundamental questions. For instance, who decides whether life is worth living or not? Should people have the right to decide when and how they will die? Though many believe that dying would be preferable to suffering and enduring great pain while trapped in an a shell of a body, a significant number also argue that people do not have the capacity to decide when life starts or ends, either on the basis of moral theology or other philosophical basis, which will be discussed shortly. Furthermore, is euthanasia a merciful killing of terminally ill patients, or is it simply a euphemism for murder and a blatant violation of the Hippocratic oath? What are the moral dilemmas at hand here? What are the religious questions at hand? What are alternatives that can be considered? These questions establish the basis of the “right to die” debate.
The physicians dilemma remains the conflict between preserving the life of the patient versus respecting the patients autonomy and dignity. In a legal brief released by the American Medical Association they state that:
"For over 2,000 years, the predominant responsibility of the physician has not been to preserve life at all costs but to serve the patient's needs while respecting the patient's autonomy and dignity,"
This stands in conflict with the provisions clearly outlined in the Hippocratic Oath that states:
"To please no one will I prescribe a deadly drug, or give advice which may cause his death."
Many argue that the Hippocratic Oath could not have foreseen the technological advances of modern medicine while a great number of physicians adamantly oppose such notions, countering that the Hippocratic Oath outlines exactly what the physician is obligated to do and is not interpreted depending on contemporary circumstance.
Before delving deeper into the philosophical arguments of euthanasia, it seems important to discuss the different classifications of euthanasia. Euthanasia can be carried out either with consent (voluntary euthanasia) or without explicit consent (involuntary euthanasia). Involuntary euthanasia is considered when the patient is incapacitated and cannot communicate their consent. This becomes very complicated as euthanasia by consent of proxy can establish multiple conflicts of interests. Euthanasia can also be classified as passive, non-aggressive, or aggressive. Passive euthanasia entails withholding basic treatment or administering pain medication with the knowledge that death may result. This is known as the principle of double effect. Non-aggressive euthanasia refers to the practice of removing life support by way of ventilator, feeding tube, or both. Finally, aggressive euthanasia entail administering lethal dosage of substance with the intention to kill the patient. The last two forms of euthanasia are most controversial and encompass most of the central debate.
Proponents of euthanasia most commonly argue personal choice, emphasizing that voluntary euthanasia is a fundamental principle of free choice in a liberal democracy. An individual has the right to life and that in principle implies a right to death. This implication is not understood by all as opponents deny such a right to death exists. Another prominent argument by proponents is the “quality of life” argument. The pain and suffering of the patient is incomprehensible to the external observer; it is in the best interest of the patient to end pain and suffering. Again, this argument is not accepted by opponents who contend that euthanasia is morally reprehensible; euthanasia in principle is simply a form of murder and the act of voluntary euthanasia is in essence a form of suicide, which is also scrutinized under moral pretenses. Furthermore, from a theological perspective quality of life cannot trump the sanctity of life. In Christianity, human life is a sacred entity belonging to God and humans have no authority to make decisions of choice to end ones life. Jewish Orthodox tradition shares a similar perspective, however accepts circumstantial situations where passive or non-aggressive euthanasia may be justifiable.
Proponents do not simple rely on emotional swindling. There is the practical consideration of economy. There are many areas where medical care is spread thin and the physicians focus and energy should be used for people whose lives could be saved rather than waste money and human resources on patients who do not desire treatment and prefer to die. It is an actual economic burden to keep people alive past the point they can contribute to society. This brings up the issue of the role of the physician. Critics argue that voluntary euthanasia could unduly compromise the professional roles of medical practitioners and heath care providers. The physician swear the Hippocratic Oath which forbids euthanasia explicitly and posits that the role of the physician is to provide the best possible medical care in the best interest of preserving the life of the patient. Some argue whether the Oath actually means the best interest of the individual includes situations when the individual states a desire to die. The assertion that the physician has no role in assisting in the cessation of life leads many to believe no, however there is significant debate even within the medical community. As stated previously, the AMA has noted that the physician, while looking out for the best interest of the patient, must also respect the patients autonomy and dignity.
Consider the perspective of the ethical egoist; my one and only basic obligation is to promote my own self interest. The patient therefore who wishes to die is ethically compelled to allow himself to die because that promotes his own self interest in dying. However ethical egoism is fundamentally flawed because there is conflict of interest rooted in the very principle of egoism. The physician may in fact feel that preserving the patients life is his or her primary obligation and there fore preventing the patients death would promote the physicians self interest. In this case, whose self interest takes precedence? Neither can take precedence over the other; the paradox of ethical egoism is that an ethical egoist cannot act as if he or she is an ethical egoist. The physician appears to be looking out for the patient self interest when actually he is motivated otherwise. The patient assumes to look out for the self interest of everyone involved including the family and the medical staff but in reality he is motivated by other self interests. As stated before, this essentially places multiple parties in conflict of interest.
Kant would suppose a different set of rules to be applied in this case. First, Kant asserts that human beings are endowed with reason and freedom of will, both of which would trump personal desires of happiness. He states that nature’s aim is not simply to extend happiness but rather to allow reason to lead them achieve their own happiness. Taken in the context of our current discussion, Kant would argue that simply to relieve human suffering and pain is not satisfactory enough to claim that euthanasia is ethically or morally justifiable. Moreover, the physician would have a genuine sense of duty to preserve the life of a patient rather than accommodate the death of a patient. For Kant, there is a fundamental difference between a personal desire and a personal sense of duty. A sense of duty is universal and can dictate what one ought to do in similar situations whereas desires are whimsical and transient. Therefore, ones desire to die as a result of pain, suffering, or a lack of motivation to continue living is not a decision that results from the rational nature of humans, but rather is a “spur of the moment,” non-rational decision. Kant argues that the moral value of an action is fundamentally based on the representation of law. In sum, Kant would declare that it would be against one’s own self-duty to commit suicide because suffering would outweigh pleasure if you lived. In addition, a physician has a genuine sense of duty to preserve ones life and acts as such in order to satisfy an end in itself, and not merely as a means to some ulterior motive. Therefore euthanasia cannot be justifiable under moral pretenses.
Consider the utilitarian perspective. Utilitarianism states that an a morally right action is the action that will bring about the maximum happiness or preference-satisfaction on the whole for affected parties, or as more commonly stated, the greatest good for the greatest number of people. The foundation of this philosophical theory is the idea that the consequences of an action are determined by rule of pain and pleasure. The better the consequence in terms of maximizing happiness or satisfaction, the more ethical an alternative it is. To evaluate euthanasia in light of this philosophy, we must consider the five features of utilitarianism. (1) Consequentialism: we must consider the consequences of an action; euthanasia would result in the patients desires being respected, the end of a pain-filled and suffering life, it would end the families agonizing over the weakened, undignified state of a loved one, it would allow the hospital and medical staff to move on to other more pressing cases, and it would take away the economic burden of keeping the patient alive on life-support. However, it would also question the fundamental role of the physician and establish a dangerous precedent. Though some argue that human dignity is not respected when a person lives off of life-support, it may also be argued that the practice of killing off people found to be suffering or feable-minded may easily diminish the essential value and dignity of life from a “greater society” perspective. The alternative is not performing the euthanasia, in which case the patient’s desires are not respected, the patient remains in pain, the family continues to agonize, and the health care providers must continue to allocate resources to the patient. However, the physicians role need not be questioned, the sanctity of life is preserved, and there is no harmful precedent being set. Since all the consequences of pain or pleasure are give equal value under this system, we consider the greatest net balance of happiness and preference-satisfaction over pain and dissatisfaction. One contend that euthanasia presents the greatest net benefit to the greatest number of people involved.
However, there are several problems with this analysis. In the above analysis we assumed we were discussing voluntary euthanasia. In the case of involuntary euthanasia, this situation becomes more complicated and one could argue in favor of either direction. Furthermore, utilitarianism does not consider several important factors such as the transient nature of many human decisions and preferences and the limited nature of knowledge when accessing “happiness” of the different parties involved. Moreover, the objectification of pains and pleasures in addition to the normalizing of value systems may pose problems for people who consider certain consequences more relevant than others. Finally, it is usually very difficult to determine all of the potential consequences of an action or take into account all the possible alternatives. Utilitarian calculations can therefore argue either side of the “right to die” debate, although it does not present as strong an argument as does other theories.
There are many viable arguments that can be posed for or against the practice of euthanasia, as the assessment thus far indicates. Nevertheless, I conclude this discussion by presenting my own perspective on the issue. In my reasoned opinion, I affirm my belief that euthanasia cannot be considered an ethically or morally sound practice on the basis of two fundamental reasons: (1) it undermines the dignity and integrity of the medical profession, and (2) it undermines the dignity and sanctity of human life. The first reason is important because as outlined in the Hippocratic Oath, the physicians ultimate role and obligation as a trusted practitioner of medicine is to respect and preserve the patients life. The patients autonomy does not trump this obligation if it in fact comes into conflict with the idea of preservation of life. Furthermore, a patients personal dignity is not respected or honored if the decision is to terminate the patient’s life. This leads into the second reason, which is the preservation of human dignity and the respect for the sanctity of life. When the common debate turns to a situation where one questions how dignity is being preserved when a person is kept on life support for years against their will or the will of the family, I counter by stating a person on life support is not a person with fulfilled life, in the sense that life support does not equate to true, independent human life. As a result, passive and non-aggressive euthanasia must be seen in a different light than aggressive euthanasia.
Much of the current legislation on this issue assumes life support on par with a normal human life. An individual should be medically cared for to the maximum ability of the care provider, but when medicine cannot help the situation of the individual, the natural circumstances should be allowed to take its course. In the Quinlan case, the family did allow Karen to naturally pass, as there was nothing medically that could have been done to improve her situation. The fact that she survived for nearly a decade after removing life support may indicate that there is potential for future medical advancements in aiding PVS patients. In summary, a person cannot decide or chose a point of death, but moreover it is beyond the scope of a physician’s obligation to assist a patient in suicide. As I stated, euthanasia undermines the integrity of the medical profession and undermines the sanctity and dignity of life.
Works Consulted
Cohen-Almagor, Raphael. The Right to Die with Dignity: an Argument in Ethics, Medicine, and Law. New Brunswick, N.J: Rutgers UP, 2001.
Dorkin, Ronald. Life's Dominion: an Argument About Abortion, Euthanasia, and Individual Freedom. 1st ed. New York: Knopf, 1993.
"Right to Die." Public Agenda. Jan. 2008. Public Agenda Org. 4 Mar. 2008 <http:// www.publicagenda.org/issues/frontdoor.cfm?issue_type=right2die>.
United States. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to Forego Life-Sustaining Treatment : a Report on the Ethical, Medical, and Legal Issues in Treatment Decisions. Washington, D.C.: U.S. G.P.O, 1983.