1. Ethical Issues of Life and Death Chan Ho Mun, Ph.D. Associate Professor of Philosophy Department of Public and Social Administration City University of Hong Kong June 22, 2006

2. Issues Abortion Abortion Suicide Suicide Euthanasia Euthanasia Physician Assisted Suicide Physician Assisted Suicide Advance refusal of treatments (Advance directives) Advance refusal of treatments (Advance directives)

3. Methodology Top-down approach: You start with a defense of some principles or abstract ideas, and then apply them to analyze an ethical issue. 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. Bottom-up approach: Compare like with like or identify the difference among cases. A Combined approach A Combined approach Critical thinking is essential Critical thinking is essential

4. Top-down Approach A principle-based argument against abortion A principle-based argument against abortion –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 wrong.

5. Objection 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. Both sides accept the sanctity of human lives, but the issue cannot be resolved solely by appealing to this principle.

6. Bottom-up Approach A defense of abortion: 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.

7. An argument against abortion (Marquis): 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.

8. The Importance of Critical Thinking Principles can be inconsistent, and resolution is needed when conflicts arise. 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. 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.

9. 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 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. 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.

10. 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 welfare principle: Human actions should always seek to promote human interests and well-being, and should always try to reduce pain and sufferings.

11. The Crux of the Problem The three principles are not necessarily consistent. How to resolve the tension among them when conflicts arise? The three principles are not necessarily consistent. How to resolve the tension among them when conflicts arise? Four approaches: Four approaches: –Euthanasia –Physician assisted suicide –Pro-life approach –Advance directives

12. Euthanasia 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 principle.

13. Voluntary, Involuntary, and Non-voluntary Euthanasia Voluntary euthanasia: The patient chooses it. Voluntary euthanasia: The patient chooses it. Involuntary euthanasia: It is offered against the wish of the patient. 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. 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.

14. Active and Passive Euthanasia Active euthanasia: An active measure, such a lethal injection, is used to terminate the life of a patient. 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. Passive euthanasia: A deliberate attempt of not saving the life of a patient. Is the moral difference between active and passive euthanasia significant? Is the moral difference between active and passive euthanasia significant? James Rachels: They either stand or fall together. James Rachels: They either stand or fall together.

15. Physician Assisted Suicide (PAS) The justification is the same as euthanasia. The justification is the same as euthanasia. The doctor involved cannot be said to have killed the patient. The doctor involved cannot be said to have killed the patient.

16. Utilitarian Argument Against Euthanasia and PAS Whose welfare? Social or individual? Whose welfare? Social or individual? Some people may feel being pressured to choose euthanasia or PAS. Some people may feel being pressured to choose euthanasia or PAS. Non-voluntary or even involuntary euthanasia will become more widespread. Non-voluntary or even involuntary euthanasia will become more widespread. Palliative care and hospice services will become less developed. Palliative care and hospice services will become less developed. Less incentive to invent or develop more effective treatment for the terminally ill. Less incentive to invent or develop more effective treatment for the terminally ill.

17. A Pro-life Approach The intrinsic value of life is absolute. It can override the principle of autonomy and the welfare principle. 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. 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. 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 is morally wrong and should even be regarded as a criminal offence.

18. Suicide: Do we have a right to die? It is not a criminal offence. It was decriminalized years ago, so strictly speaking, people do have some liberty to terminate their own lives. 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 rights. 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 rights.

19. 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. 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? So is the intrinsic value of life absolute?

20. 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.

21. 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. This approach tries to pay due respect to all the three guiding moral principles.

22. Is It a Form of Euthanasia? No. No. Argument from Autonomy: The attending healthcare team just follows the wish of the patient. 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 Intentionality: The attending healthcare team has no intention to kill the patient or hasten his/her death.

23. 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 them. 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 them.

24. 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. 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. 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.

25. 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. 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.

26. References 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, pp.195-206.

27. 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 45-55 。 陳浩文、高永文 “ 安樂死的謬誤、病人自決權與醫 療目標 ” 《價值與社會》第一期： 1997 年：頁 137- 155.

28. 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.