Ethics at the End of Life: Assisted Death ISD II Andrew Latus June 18, 2003

Outline End of Life Issues Advance Health Care Directives Euthanasia

End of Life Issues Discussions of ethics at the end of life generally focus primarily on the ‘dramatic’ issues of euthanasia and assisted suicide Today will be no exception However, this leaves out ethical issues you may encounter more frequently as physicians

Patients’ Perspectives Singer et al (1999) report the following end of life issues as being of most concern to a group of patients surveyed: Receiving Adequate Pain & Symptom Management “I wouldn’t want a lot of pain; it’s one of the worst ways to go” 4 out of 10 dying patients had severe pain most of the time? The reference to the 4 out of 10 figure is on p. 166. It is derived from a 1997 article by Lynn et al. But note that the article appears to be about perceptions of family members on this matter. The 78% figure is cited on p. 167

Patients’ Perspectives 2. Avoiding Inappropriate Prolongation of Dying “I wouldn’t want life supports if I’m going to die anyway.” 78% of health care professionals surveyed thought the treatments they offered were too burdensome? Problem of getting info about specific treatments, but not the big picture Role of the physician in giving a ‘realistic’ picture 3. Control Over End of Life Decisions “It’s very, very important to me that I can make choices for myself.” More about ‘big picture’ decisions than narrow specific decisions about treatment?

Patients’ Perspectives 4. Being a Burden on Loved Ones Making substitute decisions Witnessing their death Providing care 5. Involvement of Loved Ones Considering an advance directive “helped me get closer to my family … There were so many times I wanted to get their opinion on certain things”

Advance Health Care Directives See material from Geriatrics session Notice that many of the issues mentioned by the patients could be at least partially dealt with via an Advance Health Care Directive Caution: Don’t overestimate the usefulness of an AHCD for matters other than identifying a decision maker. It’s hard to anticipate all eventualities.

Euthanasia A broad range of activities are sometimes classified as euthanasia Withholding treatment Withdrawing treatment Taking action to end someone’s life Providing someone with the means to end his/her life What all of them have in common is that they involve situations in which: Someone, perhaps the patient, deems it better that the person we are concerned with dies than that efforts to treat the patient continue and Some course of action or inaction is undertaken with the understanding that it will bring about the death of the person Note that the deemed better clause must be interpreted very broadly. The ‘deeming better’ may only be because this is what the person wants.

Is Euthanasia Ever Morally OK? If we give the term a broad reading, most people will answer ‘yes’. E.g., Suppose Tom has terminal cancer and that all conventional treatments have failed. Left untreated, he will die in a few days. However, there is an experimental drug that has shown some promise in treating cancers like his, but that also has some very unpleasant side effects. Few would argue that it is immoral if Tom’s doctors accept his wish to refuse taking part in this experiment. The question thus becomes: under what conditions is euthanasia morally acceptable?

Some Distinctions Discussion of particular cases often turns on the type of euthanasia involved: Assisted Suicide Voluntary vs. Non-voluntary Euthanasia Active vs. Passive Euthanasia

Assisted Suicide Not actually euthanasia, since the 'patient' ultimately kills himself or herself. The line between the two can, however, become very thin.   e.g., Dr. Jack Kevorkian's 'Mercitron'   Many of the same issues arise in considering assisted suicide as in considering euthanasia Remaining focus will be on euthanasia

Voluntary vs. Non-voluntary Euthanasia Voluntary - killing or letting die a competent person who has expressed a desire for this (usually over a sustained period of time). Non-voluntary - killing or letting die when the patient is unable to express such a desire Note: there is a difference between involuntary and non-voluntary Involuntary euthanasia is not a seriously considered possibility

Active vs. Passive Euthanasia Active - roughly, involves killing a patient E.g., administering a fatal dose of morphine to a terminally ill cancer patient This is often what people have in mind when they simply speak of euthanasia Be careful to distinguish killing from murdering (‘wrongful killing’) – not all killings are murders Passive - roughly, involves letting a patient die E.g., failing to revive a patient who has signed a DNR order Generally, passive euthanasia is looked upon more favorably than active euthanasia

Forms of Euthanasia The distinctions may be combined Voluntary passive euthanasia (VPE) Voluntary active euthanasia (VAE) Non-voluntary passive euthanasia (NPE) Non-voluntary active euthanasia (NAE) VPE is the least controversial form of euthanasia   a competent patient has a right to refuse treatment

Forms of Euthanasia NPE is now broadly accepted in at least some situations (e.g., a neonate with almost certainly fatal birth defects) There are limits, however, e.g., in the Stephen Dawson case, S.D.’s parents were not allowed to refuse lifesaving treatment even though they felt S.D. would be better off dead Any form of active euthanasia is much more controversial, so we will examine the active/passive distinction more closely

Two Kinds of Passive Euthanasia (i) Withholding of Treatment e.g., not performing a needed surgery or not administering a needed drug (ii) Withdrawing of Treatment e.g., turning off a respirator Question:  While i above seems clearly passive, why is withdrawing of treatment passive? Rachels: "what is the cessation of treatment ... if it is not 'the intentional termination of the life of one human being by another'?" (pp. 79-80) The AMA began distinguishing between withdrawing medical support and active euthanasia in 1986.

Karen Quinlan 1975 - Quinlan goes into a drug induced coma Suffers anoxia causing irreversible brain damage Required a ventilator to live Not brain dead, but in a persistent vegetative state Quinlan’s sister - "If Karen could ever see herself like this, it would be the worst thing in the world for her." Hospital - '1 in a million' chance of recovery Family sought to have her removed from the respirator, doctors & hospital refused

Why Was the Cruzan Case Controversial? AMA Declaration (1973) “The intentional termination of the life of one human being by another … is contrary to that for which the medical profession stands… … The cessation of the employment of extraordinary means to prolong the life of the body when there is irrefutable evidence that biological death is imminent is the decision of the patient and/or his immediate family.” (Rachels, 78) Note the word ‘extraordinary’ In 1975, the AMA did not draw a clear distinction between withdrawing treatment and active euthanasia In 1986, the AMA adopted a policy which clearly drew this distinction CMA Code: “17. Ascertain wherever possible and recognize your patient’s wishes about the initiation, continuation and cessation of life-sustaining treatment.”

The Outcome 1976 - N.J. Supreme Court overturns a lower court decision and rules in favour of the Quinlans. Doctors 'weaned' her off the respirator in a successful attempt to keep her alive. Died of pneumonia - June 13, 1986 This case reminds us that standards regarding ethical matters can change very quickly. The Karen Quinlan case would be much less controversial today. Is the lesson of the case that the line between active and passive euthanasia is uninteresting morally speaking?

Rachels on Active vs. Passive Euthanasia Rachels: Active euthanasia is not necessarily worse than passive euthanasia Objection: Killing is worse than letting die! Response:  Rachels claims that we have been misled by the fact that most actual cases of killing are morally worse than most actual cases of letting die Because of this, we have mistakenly concluded there is some deep moral difference between killing & letting die.

Cases (i) A unconscious patient will almost certainly die unless paced on a respirator. His family explain he has expressed a clear desire not to be placed on one. He is treated according to those wishes and dies. (ii) Case i, but the man is placed on the respirator before his family arrive. After his wishes are explained, he is removed from the respirator and dies.   Are these cases of killing or letting die? Are these cases morally different?

Cases (1) A man drowns his young cousin so that he won't have to split an inheritance with him. (2) Case #1, except, before he can kill him, the cousin slips and falls face down in the bathtub. The man just has to watch his cousin drown.   Are these cases of killing or letting die? Are these cases morally different?

Cases (a) In accordance with an ALS patient's wishes the doctors remove her from her respirator. She dies. (b) A greedy son removes an ALS patient from her respirator because he wants to collect his inheritance. She dies. Are these cases of killing or letting die? Are these cases morally different?

Is Rachels Right? Do the cases make a convincing argument that the difference between active and passive euthanasia is morally irrelevant? If so, then what is morally relevant?

The Law Very roughly, the following summarizes the Canadian legal situation re. euthanasia voluntary passive euthanasia = legal in fact, required – no consent, no treatment voluntary active euthanasia = illegal although see ‘The Doctrine of Double Effect’ not true in all countries (e.g., Netherlands since 2001) non-voluntary passive euthanasia = legal under appropriate proxy decision only non-voluntary active euthanasia = illegal although again see ‘The Doctrine of Double Effect’ assisted suicide = illegal not true in all countries, e.g., Oregon’s Death with Dignity Act

A Closing Issue: The Doctrine of Double Effect (DDE) Suppose an action (e.g., giving a terminally ill cancer patient morphine) has some reasonably foreseeable result (e.g., quickening the patient’s death) and that it would be unacceptable to perform this action for the purpose of bringing this result about. The DDE claims that it may still be acceptable to perform this action, provided that the action is not performed for the purpose of bringing this result about. E.g., it may still be acceptable to give the patient the morphine provided that it is given in order to control his pain, not to hasten the patient’s death The DDE is commonly, if not explicitly, appealed to in practice. As a result, VAE & NAE may sometimes be practiced.

The DDE in Practice “Doctors should feel comfortable giving as much pain medication as it takes to ease suffering, even if it hastens death … The key is a doctor’s intent when giving drugs.” (CBC story on consensus guidelines re. palliative care and analgesia, 2002) Does the DDE make theoretical sense? Does the DDE make practical sense?