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... (p. 17) "Elderly and disabled patients are often invited by our achievement-oriented society to see themselves as useless burdens on younger, more vital generations. In this climate, simply offering the option of "self-deliverance" shifts a burden of proof, so that helpless patients must ask themselves why they are not availing themselves of it. This situation might lead some to "voluntarily" decide to end a life that is perceived as worthless. " The ever increasing costs of health care, especially for the terminally ill and those on life support systems, might also serve to influence some toward a decision for an early death. "The growing incentives for physicians, hospitals, families, and insurance companies to control the cost of health care will bring additional pressures to bear on patients. " (Doerflinger, p. 17) Proponents contend that carefully drawn laws and the use of balancing tests already in place can effectively eliminate such concerns (Gifford, p. 1563 - 64). Widespread active euthanasia might also serve to destroy the ethical image and trust of the medical profession. The public might fear that doctors are too eager to use the new techniques at their disposal and be scared away from proper health care. People could become frightened of their doctors and would no longer view them as friends and helpers, but as potential enemies. "The prohibition of killing is an attempt to promote a solid basis for trust in the role of caring for patients and protecting them from harm.
This prohibition is both instrumentally and symbolically important, and its removal would weaken a set of practices and restraints that we cannot easily replace. " (Beauchamp & Childress, 1989). "Some writers contend that legalization will reduce the public's trust in doctors and in the health care system. Michael Levy warns of the erosion of 'trust that the health care delivery system will do everything possible to relieve suffering prior to terminating life. ' Dr. Alan Stone claims that 'it is destructive to the public good to make people worry that when they go to a hospital the doctor is thinking about whether to allow them to live or die. When I go to the emergency room, I want to know that the doctor is going to do everything to keep me alive. I do not want to go to somebody who has had a class on ethics and is thinking maybe I would prefer to die. '" (p. 170) However, Newman goes on to present some convincing arguments against this position, stating that the public already views the medical profession with distrust and that this distrust is likely to grow since doctors frequently have poor communication skills, and spend little time with individual patients. As over reliance on technology increases and as hospitals and nursing homes continue to increase already exorbitant fees, this distrust is likely to increase.
Newman even contends that a caring program of active euthanasia and physician assisted suicide might actually serve to increase public trust in the medical profession and serve to reduce some of the impression that doctors and health care institutions only care about the bottom line (p. 170 - 171). Perhaps the most intriguing argument against legalizing active euthanasia is presented by Elizabeth Wolf (1989). She argues that legalization will destroy the gains made in the domain of passive euthanasia, especially for those who are not considered terminally ill. If active euthanasia were legalized, the courts would certainly have a heightened interest in regulating the space that surrounds the issue and would have a much greater profile around the bedside.
Wolf contends that this could prevent some passive euthanasia deaths that are currently allowed from happening, and that much stricter regulation on the part of the legal system would actually make it more difficult to end the suffering of those who want to die (p. 13 - 14). The arguments put forth by proponents of euthanasia are less numerous than those of their opponents and are generally based on rights premises. As advocates for policy change away from the status quo, proponents spend a great deal more time in a defensive posture, responding to the arguments of opponents and defending their own from attack. The linchpin argument of euthanasia proponents concerns the right to die. They contend that the individual has certain rights guaranteed under the law and the Constitution that allow them to choose when they can die. These rights are generally argued from the standpoint of autonomy or self-determination, or from the constitutional right to privacy.
Proponents contend that individual liberty is a fundamental constitutional guarantee, and that the right to privacy protects the right of an individual to choose to die. Wolhandler (entire article) argues forcefully that the constitutional right to privacy elucidated in Griswold v. Connecticut and expanded in Roe v. Wade, also applies to euthanasia; thus protecting the individual from the purview of the state if that person chooses assisted suicide or active euthanasia. He also argues that the protection of the right to self determination is the key to democracy and the social contract on which this nation is built when he says: "Recognition of the right of self-determination is the condition for the concept of a community not based on force.
Force used to impose on others, against their wishes, what one thinks is best for them is thus not allowed. This view undergirds a peaceable accommodation to the fact that there is a pluralism of moral beliefs: although one may not be able to agree about what constitutes good life or good death, one can agree to let each make his own choices, as long as those choices do not involve direct and significant violence against others. " (p. 370) There is some doubt, however, about whether the Supreme Court in its current configuration would be willing to extend a right that is not specifically stated in the Constitution to cover such practices (Gifford, p. 1576 - 77). In the Cruzan decision, the Court seemed quite willing to let questions of this nature be settled by the states (Cruzan, p. 2842). As we have already seen, the argument for privacy and autonomy has generated considerable support in the realm of passive euthanasia. It is the support that the courts have given to passive euthanasia that provides the basis for a second and perhaps the most crucial argument. This is the argument that the passive / active distinction made by the courts and the medical profession is invalid, cannot be made, and in actuality does not exist.
If it can be proven that this distinction is invalid, then all of the rights that allow for passive euthanasia would then allow active euthanasia as well. Advocates present a variety of different reasons for why the active / passive "bright line" cannot exist. The first argument in support of this position claims that court decisions about the interest of the state make the active/ passive distinction irrelevant. According to Adams, et. al. (p. 2034), "when considering the state's interest in preserving an individual's life in a suicide assistance case, a court should find that, absent evidence of coercion or the patient's incompetence, the state's interest is negligible compared with the patient's interest. " This logic would presumably apply to cases of active euthanasia as well.
A second argument concerns the transparent nature of the distinction itself. "It is sometimes claimed that the "passive" techniques are morally acceptable because they allow for a natural death, while "active" techniques independently cause death. But in the modern medical setting, these terms and distinctions are ephemeral. The concept of natural death in the hospital has lost its meaning. 'If you want to have a natural death, 's ays Dr. Alan Stone, 'you have to stay out of the doctor's hands. ' If you make it alive to the hospital, medical technology derails nature and alters the course, experience, and timing of death. " (Newman, p. 166) In this respect, the nature of technology almost demands that euthanasia be deployed as an option in some cases, because it prolongs life unnaturally. Additionally, the nature of the activities involved in both active and passive euthanasia, as well as the decision making process, makes the active / passive distinction a difficult one to understand.
Adams says that "Opponents of physician assisted suicide argue that it is fundamentally different from the refusal of treatment. Their arguments rely on the existence of alleged bright line distinctions between suicide and natural death, killing and letting die, or active and passive euthanasia. These distinctions rest, in part, on supposed differences between acts and omissions. However, the attempt to draw such bright line distinctions between acts and omissions fails in practice and in theory. It is often difficult, in the hospital or the courtroom, to state decisively whether something is an act or an omission. Is a physician who turns off a functioning respirator "actively" turning off a machine or "omitting "to provide air?
Is a patient who refuses food and water "actively" starving or "omitting" to eat?" (p. 2028) A third argument examines a specific death situation that has blurred the active / passive line to the point where it no longer exists. When people are in a great deal of pain, the amount of medication required to provide relief from the pain can be so great as to cause death. When a physician administers pain medication in a significant dose, is this active or passive? Vaux (1989, p. 20) states that "A second class of actions can be designated "double effect euthanasia. " Theologically and morally it is acceptable for a patient to choose palliative treatments that may result in death and for a physician to administer potentially lethal analgesia in the relief of pain.
And many ethicist's argue that the administrator of a lethal dosage is not culpable if his primary intent is to relieve suffering, though the ensuing death may be foreseeable, so long as the patient and family consent. We might understand Debbie's case (4) best from this perspective. " Clearly, in a case like this it is difficult to see whether the act should be considered active or passive. Thus, the main argument made by proponents of euthanasia argues that the courts have already allowed certain fundamental rights to protect the process of passive euthanasia, and since there is no logical or fundamental difference between active and passive euthanasia, or at least no way to demarcate such a difference clearly, then active euthanasia and assisted suicide ought to be legal as well. Interestingly, it may be just this type of logic that opponents of euthanasia see as the "slippery slope" discussed earlier. Active euthanasia would allow the individual control, choice, and a greater ability to face suffering and death effectively. According to Newman (p. 183), "A total ban on assisted deaths might have another unintended, detrimental effect.
Persons with diseases like Alzheimer's are now tempted to try suicide at an early stage of their disease when they are still mentally and physically fit. If they knew euthanasia were available later, perhaps through an advance directive or health care proxy, these individuals might choose to live longer, through a later stage of the illness. " It is also worthwhile to remember that Dr. Quill's patient was able to face death much more calmly knowing that she had the ability to end her life when she chose. This enabled her to spend her energy strengthening her connections with her family and enjoying the time she had left. Euthanasia prevents state control. The state has no right to coerce the individual or control the body of the individual unless there is some sort of compelling interest.
The balancing tests that courts use in the case of passive euthanasia are just as valid in the cases of assisted suicide and active euthanasia. Because there is no state interest in most cases, this proves that the practices stated above should be legal. Engelhart (1989, p. 8 - 9) argues that the state has no moral authority to prevent euthanasia. This is because euthanasia is a negatively established right. He says that "The right to euthanasia, like most other rights to act freely by oneself or with consenting others, is established negatively. It does not depend on some claim that such liberty would be good, beneficial, or worth endorsing.
Rather, it is a function or the failure to establish the authority of others, in particular, the state, to intervene coercively. With this, one comes face to face with the plausible limits of a secular state. One will need to live with individuals' deciding with consenting others when to end their lives, not because such is good, but because one does not have the authority coercively to stop individuals acting together in such ways. In a secular, pluralist society one will need to accept euthanasia by default. " These arguments constitute the major offensive positions taken by euthanasia advocates. The other two arguments, that euthanasia might actually increase the level of trust among patients and the public toward the medical profession, and that euthanasia would also prevent abuse by providing a clear set of guidelines regulating the behaviors of various actors, have already been dealt with as responses to the opponents of the practice. V.
Normative Ethical Theories and Euthanasia As stated at the beginning of this paper, the controversy regarding the practice of euthanasia is essentially a controversy about ethics. The debate about euthanasia is a value debate among people who weigh values differently, who see the nature of the world and the place of humans in that world differently. The differences between those on opposite sides in this debate can best be seen through an examination of value hierarchies. A value hierarchy is the manner in which a person orders his or her value system by ranking different values in order of importance. Perhaps the most famous value hierarchy was developed by Abraham Maslow (1954). His hierarchy of needs attempts to explain various facets of human behavior by showing how people can move up or down the hierarchy depending on which needs are met.
All types of values can be organized in hierarchies. Proponents of euthanasia have a different value hierarchy than do the opponents. Doerflinger clearly argues for a particular value hierarchy when he contends that life is the supreme good and that all other goods must come only after life is secured. His logic states that without life, no other value or good can exist, and therefore it is a prerequisite for all other values. Proponents of euthanasia also believe in the value of life, but they don't place it as highly on their hierarchy.
Instead, a proponent of euthanasia might argue that individual rights are the supreme value, or that quality of life is more important than the value of life itself. The logic here is that although life is clearly an important value, there may be times when life itself is not worth living. If a person has no individual rights, or if a person has a low quality of life, they may make the decision to end their life because it is no longer worth living, no longer a good life. One of the main reasons that the debate about euthanasia has been so hotly contested is because it challenges the value systems of people.
The people who believe in individual rights and quality of life as the supreme value see their value hierarchy threatened in the status quo by the power of the state. If the status quo were to change to eliminate this threat, people who see life itself as the supreme value would find their value hierarchy threatened. One way of examining values and ethics to see if they are worthwhile is through the use of normative ethical theories. By examining a problem or particular policy through the lens of a normative ethical theory, we can determine if the system needs changing or if a particular policy option is an ethical one. There are several normative ethical theories that have been proposed by philosophers. I will examine ethical egoism, utilitarianism, and rights theory; and then use these theories in order to analyze the problem of euthanasia.
This might give us a basis for determining whether or not the practice of euthanasia is ethical. Ethical egoism was first propounded in modern times by Thomas Hobbes in Leviathan. It operates from the general rule that if any action increases my own good, then it is right. Hobbes argued that we cannot help but act in our own self-interest, and therefore, such actions are ethical (Rosen, 1990, p. 37 - 44). Ethical egoism in the context of euthanasia would contend that if a person wants or does not want to end their life using euthanasia, this desire is motivated by a need for self benefit, and is therefore an ethical action. Utilitarianism was most completely articulated by John Stuart Mill in On Liberty.
It operates from the general rule that if any action increases overall good, then it is right. The corollary to this is that if any proposed direct moral rule, when generally acted from, increases overall good, then it is a correct direct moral rule (Rosen, p. 45 - 52). In the context of euthanasia, we must examine the practice to determine if it increases the overall good in order to determine if it is ethical. Rights theory has a well-established pedigree in American thought. Based on Kant and Locke, Jefferson and other founders of the United States used rights theory as the basis for government. Rights were established in the constitution and assigned to the judiciary for their protection.
Rights were conceived of as natural, protected by law but not created by law. There are very few natural rights, and most of these are established negatively (Rosen, p. 62 - 64). As we have already seen, euthanasia proponents rely heavily on rights theory as justification for euthanasia. (5) These normative ethical theories can be used to illustrate the conflicts that surround the various actors involved when the problem of euthanasia must be considered. When such a decision must be made, there are several points in the system where a decision can potentially occur.
These points are where the decision makers reside: the individual, the family, the physician, and the state. In each of these cases, there are normative ethical theories that can illustrate the value conflict which occurs at each level. At the individual level, the person must make a decision whether or not to end their life. The normative ethical theories of ethical egoism and utilitarianism illustrate the value conflict and the ethical dilemma involved. Egoism may lead one to want to die, as the individual may believe that based on their self-interest and to their personal benefit, it would be better to die. The individual may be experiencing a great deal of pain, loss of bodily functions, and faced with spending the remainder of their life as an invalid.
On the other hand, egoism may lead one to want to live under conditions that might dictate otherwise. A person might argue that all available medical technology ought to be brought to bear in the preservation of their life. In the case of a utilitarian perspective, a person may choose to live for the good of others. For the sake of loved ones and the pain they might feel because of death, or because of the premium that society places on life, a person may choose to go on living even though they might make an individual choice to die if such considerations did not exist. By the same token, a utilitarian perspective may lead a person to choose death. The pain and financial burdens that family members or society might have to endure could be so great that although the person might want to go on living, it would be in the best interest of the family or of society that the individual should choose to die.
The family might also experience an ethical dilemma that is also illustrated by the competing theories of ethical egoism and utilitarianism. This dilemma would be most relevant in the case of an incompetent individual who is unable to make their own decision whether to die. Egoism might lead the family to choose to keep the individual alive because they are unable to live with the knowledge that they pulled the plug on a loved one. They would be more at peace knowing that they had done all they could to keep the individual alive. Alternatively, egoism might entice the family to choose to allow the individual to die.
They may conclude that the emotional and financial trauma on the family would be so intense that it would be in their best interest to prevent medical treatment from continuing. A utilitarian perspective may cause the family to keep an individual alive. They may decide that it is harmful to society to weaken the value of life, and that if there is a possibility of saving life, in any condition, it should be done for the good of everyone. However, the same perspective may lead the family to conclude that the individual should be allowed to die. They may believe that society would be forced to bear the financial burden of an individual utilizing such expensive medical care, and that such resources might be better allocated if they were used on those who were not beyond hope.
The physician also faces an ethical dilemma. The universal imperative of the profession revolves around the Hippocratic Oath. Doctors have a duty to preserve life at all costs. Society commits physicians to preserve life.
Since life is a most precious commodity, nothing should be done to take it away. It is the universal imperative that generates arguments by the AMA and other opponents of euthanasia which intimate that the practice would severely damage the ethical image of the profession. In conflict with the universal imperative stands the doctrine of patient autonomy and the rights of the patient. The physician has a duty to respect the wishes of the patient. If the patient is in a permanent vegetative state, and the individual or family has indicated a preference for the death of that person, the doctor has a duty to respect those wishes.
Rights theory and patient autonomy have generated arguments regarding paternalism, and also have led proponents to assert privacy and self-determination interests in the right to die. At the state level, the value conflict can be illustrated by examining utilitarianism and rights theory. Rights theory contends that the state has a limited right to intrude on the affairs of the individual. Only in the face of a compelling state interest does the state have the right to limit individual rights to privacy and self-determination.
In most cases, there is no compelling state interest when an individual decides to die. A compelling state interest can only exist if there is a significant threat to society, or the interest of a third party at stake. Whether these interests exist in most cases of euthanasia is open to debate. The state must make utilitarian considerations that include the risk of physician abuse, the image of the medical profession, the effect that such practices would have on the value accorded to life in society, the costs of keeping terminally ill patients alive, and the burden those patients place on social support systems.
The state must balance all of these utilitarian considerations, and then must decide what power the state has in the face of individual rights. As the above discussion indicates, even an analysis of normative ethical theories doesn't provide a clear answer to what should be done in the case of euthanasia. Normative ethical theories provide no basis for consistent decision making because there is no consensus of the good. Differences between individual value hierarchies and lack of agreement on what constitutes "good" means that people can use normative ethical theories to defend whichever position they choose to take. It is clear that most of the arguments made either for or against euthanasia are derived on the basis of normative ethical theories, but that they provide no clear mechanism for determining which decision is best.
I will attempt to provide some clearer decision making mechanisms in the conclusion of this paper. Further complicating the discussion on euthanasia are the power interests which attempt to control both the subject and the debate. Two of the most powerful professions in American society the medical profession and the legal profession have a significant stake in the outcome of the debate. Each of the professions stands to lose or gain depending on the outcome of the debate. Foucault's (1973) landmark study of the medical profession demonstrates how the medical profession has empowered itself through the development of a specific knowledge and vocabulary concerning the body. It is this discursive formation about and knowledge of the body that has given the medical profession a privileged position of power in our society.
Physicians have the power over issues of life and death in our society and they have used this power to shape the debate on euthanasia. It is also this power that has led to charges of paternalism. The specialized vocabulary and knowledge about the body, place the physician in a position to "know what is best" for the patient. If the medical community advocates a ban on euthanasia, its power over this "medical" issue gives the profession an abnormally large voice in the debate. The legal profession is in an analogous position to the medical profession. As a profession with a specialized knowledge and vocabulary concerning the legal system, the legal profession is in a similar position of power.
If the legal community advocates the legalization of euthanasia, its power over this "legal" issue gives the profession an abnormally large voice in the debate. In the case of euthanasia, we have a collision between law and medicine. The result has been a strenuously argued debate that is ultimately about which profession should have the power to make these life and death decisions. The medical profession advocates a ban on euthanasia because this will give it the power to decide when it is appropriate to terminate the life of a patient. The medical profession has a significant stake in this debate because they do not want to be seen by society as killers. They want to retain their image as healers.
More importantly, they want the power to decide when the treatment of the patient should be terminated. This is one of the main reasons for the AMA council on ethics. The profession has a stake in remaining a self regulated organization. They do not want to be subject to a variety of court decisions which regulate when they should terminate life. The legal profession is also intensely interested in euthanasia because it stands to gain if euthanasia is legalized in our currently litigious society. A system of legalized euthanasia would likely mean that the courts and the legal system would get to determine the rules under which the practice is carried out, effectively transferring a great deal of power from the medical profession to the legal profession.
Although neither side will admit that the euthanasia debate is a power struggle between two powerful professions, almost all the literature on the subject from the medical profession opposes legalization of euthanasia, while almost all the literature from the legal profession favors legalization. It is in this debate between two powerful systemic opponents that the power of the individual patient and the family gets lost. If a person wants to make a decision concerning the end of their life in the current system, they must first fight battles with the physicians or in the courts. VI. Rethinking the Ethic: A Possible Solution It is this power struggle, wherein the power of the patient is lost, that leads me to advocate a rethinking of our societal structures that surround and control our end of life processes. The discussion about euthanasia needs to be analyzed from a new viewpoint, a new paradigm, which will allow us to move outside the present debate that will inevitably empower either the medical or legal community.
The debate must be shifted to center on an approach that will empower the patient, the family, and the community. The problem of euthanasia must be viewed from both philosophical and practical standpoints, by examining the metaphysics of quality and the ethic of care. In elucidating his truly revolutionary metaphysics of quality, Pirsig (1991) argues that the world is not composed of substance, subject and object, mind and matter; it is composed instead primarily of value. He explains this radical concept by stating: "The low value that can be derived from sitting on a hot stove is obviously an experience even though it is not an object and even though it is not subjective. The low value comes first, then the subjective thoughts that include such things as stove and heat and pain come second.
The value is the reality that brings the thoughts into mind... Value is not a subspecies of substance, substance is a subspecies of value. When you reverse the containment process and define substance in terms of value the mystery (of where values exist in the world) disappears: substance is a "stable pattern of inorganic values." (p. 99, 101) (parenthesis mine) Using the terms quality, value, and moral almost interchangeably, Pirsig says that quality and morality is the primary reality of the world and that the world is primarily a moral order. There are two types of quality: static and dynamic quality. Dynamic quality is responsible for progress. It is the evolutionary force that has led to the explosion of life, the creation of cultures, cities, art, and literature.
Static quality is responsible for preservation. Once a dynamic advance has occurred, static quality is what prevents the slide back down the evolutionary spiral. Retention of adaptations such as clothing, fur, tools; and things like libraries, ritual, and laws are examples of static quality or static patterns of value preserving the advances made by dynamic quality. (p. 107 - 121) After Pirsig splits the concept of quality into static quality and dynamic quality, he then identifies four separate levels of value or quality. These he terms, in ascending order of level of evolution, inorganic quality, biological quality, social quality, and intellectual quality. Each level of quality has worth in its own right. Each higher level of quality depends on the lower levels of quality for existence, but each higher level of quality is also more valuable than its lower level cousins.
Pirsig says that "What the evolutionary structure of the Metaphysics of Quality shows is that there is not just one moral system. There are many. In the Metaphysics of Quality there's the morality called the "laws of nature" by which inorganic patterns (of value) triumph over chaos; there is a morality called the "law of the jungle" where biology triumphs over the inorganic forces of starvation and death; there's a morality where social patterns triumph over biology, "the law"; and there is an intellectual morality, which is still struggling with its attempts to control society. " (p. 158 - 159) Pirsig also contends that the Metaphysics of Quality is an excellent device for resolving ethical dilemmas. "The Metaphysics of Quality has much more to say about ethics however, than the simple resolution of the Free Will vs. Determinism controversy.
The Metaphysics of Quality says that if moral judgements are essentially assertions of value and if value is the fundamental ground-stuff of the world, then moral judgments are the fundamental ground-stuff of the world. It says that even at the most fundamental level of the universe, static patterns of value and moral judgment are identical. The 'Laws of Nature' are moral laws... When inorganic patterns of reality create life the Metaphysics of Quality postulates that they " ve done so because it's 'better' and that this definition of 'better ness " this beginning response to dynamic Quality is an elementary unit of ethics upon which all right and wrong can be based. " (p. 156 - 157) Because the Metaphysics of Quality takes such a fundamentally different view of the universe and because it claims to be able to easily resolve ethical dilemmas, it would be useful to use this new metaphysics to examine the seemingly intractable ethical problem of euthanasia. To determine which course of action is morally correct, Pirsig says the process is simple. One simply acts to preserve the highest form of evolutionary q
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