Mappes & DeGrazia, Chapter 7: Lecture Notes/Outline by Larry Hauser

Suicide, Active Euthanasia, and the Treatment of Impaired Infants

What is Suicide

The Importance of Definition

clarify the discussion & eliminate merely verbal disagreement or agreement

the Wm. James example of "going around the squirrel"

A and B and C

A says "suicide is sometimes permissible"; B & C say "suicide is always wrong"
seems like A disagrees with B and B agrees with C
but A and B mean different things by suicide

A calls a Jehovah's Witness' refusal of blood transfusion permissible suicide
B also thinks it's permissible but doesn't call it suicide
there's no moral disagreement between them just a semantic disagreement

and B and C mean different things by suicide

C agrees with A about the Jehovah's Witness: that's suicide
so there moral disagreement between B and C despite their verbal seeming-agreement

Standard definition of suicide: intentional termination of one's own life.
Cases for consideration

A woman, having despaired of achieving a satisfying life, leaps to her death from the top of a city skyscraper
An elderly man dies from a massive overdose of sleeping pills, leaving a note explaining that he is not bitter but that life seems to have passed him by.
A captured soldier, being subjected to torture, feeling he can't take any more, hangs himself in his cell to avoid "spilling his guts" to the enemy
A truck driver, foreseeing his own death, steers his runaway truck into a concrete abutment to avoid hitting a school bus that is stopped in the roadway discharging children.
Captain Oates, having fallen ill, is unable to keep up with his Antarctic exploration party. Unwilling to cause them further delay and unable to convince them to leave him behind, walks off into a blizzard to die.
A Jehovah's Witness refuses to consent do a blood transfusion and dies.

Discussion

Clear case of suicide.
Clear case of suicide.
the motive is altruistic

a case of sacrificial killing, not suicide, some would say
M&G: "a clear case"" "to deny case 3 is a case of suicide is surely to abandon the standard definition" (p. 369)

plausible to deny this is a case of suicide

the truck driver didn't intentionally terminate his life
didn't "initiated the chain of events because he desired to die"
rather it was "to attain some other objective, that is, the protection of others

so how is this different than the soldier? (LH)

controversial doctrine of double effect

death was not the primary intention of the basic action of redirecting the truck

death was a forseen but
unintended side effect of the primary action

death was the primary intention of the soldier's basic action of hanging himself

directly intended to kill himself
in order to protect his comrades in arms

other applications: abortion case

to give pregnant woman chemotherapy knowing it will almost certainly cause her to miscarry

the expulsion and death of the fetus is a fully foreseen but unintended side effect
so it's not abortion and is morally permissible

to induce miscarriage in order to save the life of the pregnant woman

the expulsion and death of the fetus is directly intended as the means to save the woman's life
so it's abortion and is not morally permissible

if the double effect analysis doesn't wash, then 3 & 4 must be treated alike

4 as suicide
or 3 as sacrificial

Captain Oates case is just like 4.
The Jehovah's witness case

CON: it may be said they don't want to die and don't intend their own death.
PRO: since they knew full well that refusal would kill them, and they didn't have to refuse, they intentionally took their own life

Active v. Passive

notice one could commit suicide by refusing medical treatment

if I refuse to be transfused
because I'm tired of living

example shows it's possible to commit suicide by passive means no less than active

active: taking an overdose of drugs
passive: refusing to eat

The Morality of Suicide

Aquinas: it's always immoral

violates our duty to God
violates natural law: it's contrary to the bodies natural urge to live
injures the community

Kant: it's always immoral

degrades human worth
it's using your humanity merely as a means to avoid some unpleasantness

The more liberal view (R. B. Brandt, Roman Stoics, David Hume)

vaguely utilitarian case

permissible to the extent that it does no substantial damage to the interests of other individuals
also no person is obliged to undergo extreme distress to spare lesser distress to others

Stoics

a deliberate death is more likely to be a good death
to cling excessively to life is unseemly and even (contra Aquinas) unnatural

The rationality issue

some maintain that a suicidal intention is necessarily irrational & thus a symptom of mental illness or incompetence
built into some psychiatric theories but considered by many philosophers to be an implausible contention

The Morality of Active Euthanasia

preliminary distinction

killing
allowing to die

narrow and broad senses of euthanasia

narrow: euthanasia is mercy killing

so "allowing to die" (e.g., by withdrawing or withholding a respirator), isn't euthanasia
thus narrowly conceived

broad sense: euthanasia is killing or allowing to die on grounds of mercy

killing = active euthanasia
allowing to die = passive euthanasia

voluntary, nonvoluntary, & involuntary euthanasia

voluntary: with the patients informed consent
nonvoluntary: with proxy consent
involuntary: without the consent or contrary to the wishes of the patient

the practice of saving the last bullets for the family in cases of injun attack
the flayer in Red Sorghum

confusion in the literature nonvoluntary (above) sometimes called"involuntary"

four types (forgetting the involuntary)

passive voluntary: widely accepted: live issues concern when it's permissible
passive nonvoluntary: widely accepted: live issues concern when it's permissible
active voluntary: highly controversial if it's ever permissible
active nonvoluntary: highly controversial if it's ever permissible

active euthanasia

James Rachels:

There's no morally significant difference between killing and allowing to die.
Allowing to die is morally permissible under certain circumstances.
:. Killing too is morally permissible in these circumstances.

Daniel Callahan

There is a morally significant difference between killing and allowing to die.
Killing -- unlike allowing to die -- "is incompatible with the role of the physician in society" which is

only to comfort
never to kill

Dan W. Brock

killing is not incompatible with the physician's role
permission of voluntary active euthanasia furthers both patient autonomy & well being

The standard case for

it's humane: often the best means to avoid further suffering & indignity
it respects the individual's autonomy

in giving them control over their dying process
while harming no one (of the liberty limiting principles only offense & morality seem to apply)

Standard appeals against

killing an innocent person is intrinsically wrong
systematic acceptance of active euthanasia would lead to socially undesirable consequences, e.g.,

lessened respect for life
less tolerance of & effort to ameliorate disabilities
less effort to ameliorate the dying process

Active Euthanasia and Social Policy

Appeal to intrinsic wrongness often religiously motivated.
Joan Tyro & Joanne Lynn appeal to adverse social consequences

abuse of vulnerable persons
disincentive to provision of support services to the dying
public confidence in physicians is undermined

The "slippery slope" argument (frequently heard): similarly appeals to consequences

acceptance of voluntary euthanasia will lead to
acceptance of nonvoluntary euthanasia will lead to
acceptance of involuntary euthanasia of those whose life society judges "not worth living"

In favor of legalization of active euthanasia

fears of adverse consequences are exaggerated
the slope is not so slippery: reasonable restrictions can be enacted

Proposed restrictions: permissible only given

terminal illness (under some definition)
unbearable suffering (under some definition)
allowing advanced directives?

The Dutch Practice

unbearable (and unrelievable) suffering is required
terminal illness is not a requirement
advance directives are honored

Margaret P. Battin

Dutch practice is morally appropriate in relation to existing social conditions in Holland
however, "the United States is in many respects an untrustworthy candidate for practicing active euthanasia"
physician assisted suicide would be a more suitable practice in the U. S.

Physician-Assisted Suicide and Social Policy

The physician's assistance

provision of information about how to commit suicide in an effective manner
provision of the means necessary for the suicide (e.g., a prescription for a lethal amount of medication)
possibly moral support on up to "supervising" the actual suicide & helping the patient carry out the necessary actions (e.g., a very frail patient may need assistance even to take pills)

The difference between physician-assisted suicide and active euthanasia

euthanasia:

the physician performs the act that directly brings about the death
Jack Kervorkian injected Thomas Youk with the fatal solution himself

assisted suicide

the patient performs the act that directly brings about the death themself
Kervorkian's previous patients flipped the switch that released the fatal solution into an intravenous drip.

controversial whether this is a difference that makes a moral difference (c.f., double effect)

RE: Legalization of physician assisted suicide

objections parallel those to active euthanasia
Timothy Quill, Christine Cassel, Diane Meier: legalize it

there is far less risk of abuse in physician-assisted suicide
with some appropriate safeguards

Another opposing point of view

since terminally ill patients are already free to refuse hydration and nutrition to bring about their death
there is no need to legalize either euthanasia or physician assisted suicide

The Treatment of Impaired Infants

Point of controversy: selective nontreatment of severely impaired newborns

a form of passive nonvoluntary euthanasia
that has been the subject of intense legal and moral scrutiny

series of "Baby Doe" cases
Reagan Administration Justice Dept. brought suit to force treatment in several cases
"Baby Doe" regulations were proposed

Central moral question: Under what conditions, if any, is it morally acceptable to allow a severely impaired newborn to die?
Closely related issues

procedural question: Who should make the decision to treat or not to treat?

some argue physicians, since, it's a medical decision
more commonly accepted view: parents

as informed by consultation with physicians
and within socially approved limits

the active euthanasia question

if these newborns are better off dead
wouldn't it be more humane to kill them as promptly and painlessly as possible

Three different views

It's morally acceptable to allow newborn infants to die if and only if death would be in the infants best interest.

firmly committed to making quality of life judgments
& the claim that some lives are of such low quality as not worth living.
reject the legitimacy of consideration of costs to others

monetary
emotional

It's morally acceptable to allow newborn infants to die if at least one of the following conditions are met

there is no significant potential for a meaningful human existence
the emotional or financial hardship of caring for the impaired child would constitute a grave burden for the family
H. Tristram Engelhardt, Jr.: since newborns are not yet persons such cost considerations are morally acceptable

It is never morally acceptable to allow a newborn infant to die.

more precisely: "it would never be morally acceptable to withhold treatment from a severely impaired newborn unless it would be morally acceptable to withhold treatment from a normal infant"

there is no moral imperative to provide treatment for a dying infant

i.e. treatment that just "prolongs the dying process"
whether the infant is normal or impaired

otherwise it is imperative to provide whatever treatment would be deemed appropriate in the case of a normal infant

e.g. it would be wrong not give antiobiotics to treat the pneumonia of an impaired infant (thus allowing them to die)
just because they're impaired

typically advocates of this view

hold that newborns have the moral status of person
with a right to life in virtue of that moral status
regard as inadmissible both

quality of life judgements
considerations of cost