Ethical Practice
The
artifact below is a paper written for my Bio-medical Ethics class as part of my
degree program. This paper was a reflection on my attitudes towards the ethics surrounding
euthanasia and dying with dignity. It allowed me to grow my perspective
regarding the ethics and allowed me to examine my previous viewpoints from an
ethical standpoint. This is especially relevant to my practice because I would
like to own my own hospice and respite facility in the future. As Canada has
now legalized euthanasia in some forms it will be something I will likely be
dealing with in the future.
Biomedical Ethics Paper as Submitted :
The Question of Ethics and Euthanasia
Lindi Puzio
Student ID: 3248792
PHIL 335
Tutor: Jill Gatfield
March 4th, 2016
The Question of Ethics and Euthanasia
The process of death and dying can be difficult for many individuals. Especially those who feel unable to help those who are suffering. Parents can feel an even greater need for this relief when dealing with the sickness of their child. Where can we ethically draw the line on allowed health interventions? Many individuals have very solidified views on the concept of active euthanasia. Active euthanasia is defined as the process of a doctor ending a patient’s life when the patient has expressed the desire for the doctor to do so, by the justification of ending suffering (McTavish, 2013, Unit 9). This paper serves to analyze the moral components surrounding the active euthanasia of a sick nine-year-old girl and come to a resolution based on analysis and moral principles. It will also explore the major moral question of whether active euthanasia should be considered to alleviate suffering of the patient and family when death is inevitable or if the passive form of euthanasia the only moral option. It will explore this question through the moral principles of autonomy, beneficence, non-maleficence, and justice. Informed consent
We can begin our discussion on this moral topic with whether in fact, Andrea a nine year old, would be considered an independent moral agent, that is having the ability to make an informed consent and have that consent valued equally. In my opinion no, she should not have equal weight to that of her parents. Let’s review the case details that would support this.
Andrea is a nine year old terminally ill girl. Some like, Harrison, Kenny, Sidarous, & Rowell (1997) would argue that children with terminal/chronic illnesses sometimes gain experience beyond their years and thus these experiences give them the maturity necessary for making informed decisions regarding their health (p.95). Harrison et al. (1997) would also classify Andrea as a primary-school- aged child (p.95). This would suggest that while the child’s assent or dissent be considered, the reasons for that may not be fully understood with the weight of issues such as life and death (Harrison et al., 1997, p. 95). Therefore, the official decision should still be left to Andrea’s parents in this case. Many case details also point to the fact Andrea may not be ready developmentally for this large of a decision. Examples include that Andrea refuses to talk with anyone but her mom (which in some ways may show immaturity), and she had many question for her mother about death and dying that were left unanswered. This may indicate that she has knowledge of death and dying but is still confused by the process and thus doesn’t not have a complete mastery of the concept. Therefore by these definitions informed consent must then fall to a proxy through her parents.
One can question whether her parents have fulfilled their duty to their child in the effort of giving consent as well. As stated in the case details when making decisions about the DNR order, Andrea was not consulted on the matter. Would their decision have changed if Andrea’s opinion been considered? Harrison et al. (1997) would suggest that only considering the parents’ wishes without the child’s wishes is inadequate, and that a “triadic relationship”, one that involves the child, parents, and physician in all decisions is fundamental to the preserving the integrity of the relations and the consent given (p.93-94). So while we can agree her parents are the ones who should be giving consent for their child, one can argue that her wishes may not have fully been considered in this case. With this knowledge then we can consider the ethical differences of active and passive euthanasia, as well as, whether one might consider this voluntary, involuntary or non-voluntary.
Voluntary, Involuntary, Non- Voluntary, or Passive?
The difference between active and passive euthanasia is defined by McTavish (2013) as: in active euthanasia a doctor preforms an action with brings about the end of a person’s life and the action taken has this intention, passive is the failure or choice not to act which brings about the same conclusion (Unit 9). Voluntary is defined as the patient has expressed desire in some way that they wish to end their life through the action of a physician (McTavish, 2013, Unit 9). Whereas involuntary could be equated with the United States execution as the taking of a life, commonly through means of lethal injection, when the patient has not expressed desire to die or has in fact expressed desire to live and injection is performed anyways (McTavish, 2013, Unit 9). Non-voluntary is deemed as when the patient cannot express their desire one way or the other (i.e. mute, severely mentally challenged, small children), and the act of euthanasia is performed through the alleged benefit to that person through the termination of suffering (McTavish, 2013, Unit 9).
In the case of Andrea one might battle with the difference ethically of active voluntary and active non-voluntary and perhaps even active involuntary euthanasia in this case, and where Andrea’s case would fall in this spectrum. Where this area becomes grey in the definition of such. Many would consider the definitions of these to be for an ideal adult situation that does not generally consider the case of the mentally challenged or child’s cases. Because this is a child’s case these definitions must be explored. With our understanding of Andrea’s ability to give consent can this be considered an active voluntary euthanasia if we have determined that she is incapable of independently giving informed consent? Many would argue no. And in the case details we know Andrea will not talk to anyone except her mother, and her opinion and wishes were not only minimally considered but also minimally expressed. Even if in the above sections we had considered Andrea able to give consent for herself, Andrea did not explicitly state she had a desire to die. So in this case it could not be considered a case of active voluntary euthanasia by this definition.
In the somewhat spine chilling consideration, could this be a case of involuntary euthanasia? Andrea did not explicitly state the desire to die but on the other hand she also did not express a desire to live. Is this then a slippery-slope-situation where this could easily become an abuse of the law if such law were in place in Canada? I would argue that no, this is not a case of involuntary euthanasia when considering the terms the definition is using. Since Andrea has been considered unable to give consent for herself without a proxy, we cannot consider this as a stated desire to or to not live. For the legal implications of this Andrea cannot legally state she has a desire to die and have a physician act upon that desire without the intervention of her parents as acting proxy consent givers in this situation. This then would be active non-voluntary euthanasia with parental consent. Andrea cannot give consent and can only express her desire through her parents’ wishes if they choose to consider that choice and therefore it can be acted upon if the physicians deemed it a benefit to Andrea in terms of relieving suffering, as well as if the laws were in place to do so within Canada.
Active or Passive?
We have determined that Andrea’s case would be active non-voluntary euthanasia. So how does it morally compare against passive euthanasia? Passive forms of euthanasia has been used in Canada is various forms for many years and there are no laws prohibiting its use (McTavish, 2013, Unit 9).
Support for Active Euthanasia. Active euthanasia must be allowed on based upon all four moral principles of autonomy, beneficence, non-maleficence, and justice.
In terms of autonomy, it gives the patient a sense of control over their disease progression. It allows them to be feel in control instead of controlled by their disease. “I want to be able to make my own decisions, instead cancer is making them for me” (S. Puzio, Personal Communication, February 8th, 2012). In terms of terminal illnesses, the disease can progress to where there are not many choices left for the patient. Giving them the freedom to choose active euthanasia is providing the utmost respect for that patient’s autonomy in the face of the biggest life event of all.
Non-maleficence is upheld through the decision to end the suffering of the patient. In terms of terminal illness, suffering can come in many forms. Just like pain is a subjective quality, suffering is also subjective (Battin, 1987, p. 324). Even with the advancements of pain control therapies, a person not experiencing pain can still suffer (since it is subjective); suffering may be the extreme nausea as a side effect of the pain medication (Battin, 1987, p. 324). Since suffering is not exclusive to pain only, it is not a fair statement to state that the need for active euthanasia is mitigated through the advancement of pain control therapies (Battin, 1987, p. 323). Suffering may be the imprisonment felt through the loss of ability with MS and ALS patients. We cannot judge there suffering as it is felt only by the person feeling it (Battin, 1987, p. 328).
Beneficence is a moral principle that ties to non-maleficence. In many ways it can be argued through the point of mercy. Allowing active euthanasia also satisfies the “duties of medicinal mercy” as stated by Battin (1987): “1. The duty not to cause further pain or suffering and 2. The duty to act to end pain or suffering already occurring “(Battin , 1987, p. 322). If we can morally justify the act of passive euthanasia or withdrawing treatment that would lead to a patient’s death based on the principle of mercy, then those same justifications can also apply active euthanasia, especially where death is imminent and further suffering is unnecessary (Battin, 1987, p. 323). Palliative care does not mean the termination of any interventions, instead it means the use of comfort care measures to relieve symptoms without the underlying attempt at a cure of disease (Palliative, n.d.). No one would argue with the moral rightness of palliative care for those who wish to utilize it. With this is mind we can equate active euthanasia with a form of palliative care, but ending a person’s suffering you are also in turn ending any unpleasant symptoms of their disease they are experiencing. In this view we can see how for those who wish to utilize active euthanasia, it can bring great beneficence.
Justice can be served not only to the patient in weak form of respecting their wishes and allowing their vision for life to come to fruition, but also through the justice we owe to others. Battin (1987) also argues about resource allocation to those in need, who can have a future, and who also wish to have a future (pp. 331-332). Through the act of legalizing euthanasia we are also serving justice through giving future patients the ability to think and consider their options ahead of time, before an illness makes them unable. It can allow for the proper advance directive and proper legal channels to be explored before a patient is suffering.
Support against Active Euthanasia. With the act of asking a physician to set their moral principles of their own aside to perform the active euthanasia, we are also asking the physician to go against the basic principles of medicine of preserving and promoting health (Callahan, 1992, pp. 346-348). Denying legalization would be an exercise is justice and autonomy in the support of the physician. As the physician would be acting as a separate moral agent in this situation. Huddle (2012) would also suggest there is very distinct moral difference between the act of allowing and the act of doing. When one is a bystander in the death of another we can consider this as allowing; when one is a facilitator or maintains something which leads to the death of another this is doing (Huddle, 2012, p. 261). These are two very distinct actions. Therefore we cannot consider passive forms and active forms as equal. The act of doing is what is moral unethical. As the act of allowing does not necessary cause death, death is merely as consequence of a pre-existing condition (Callahan, 1992, p. 346; Huddle, 2012, p. 261). Callahan (1992) used the example of stopping medical treatment of a patient; if this were a reasonably healthy person, death would not be inevitable and thus death would not occur, where as if the pre-existing condition of terminal cancer exists cancer would eventually lead to the death of the patient. Therefore in this case the doctor is not the cause, instead cancer is the cause; he is merely allowing that to happen. Huddle (2012) uses the example of three jumpers and a firefighter. The firefighter must make a decision with a safety net of who to save, one jumper or two together (Huddle, 2012, p. 261). If the firefighter moves the net to save the two instead of the one, we call this allowing the one man to die, with a “pre-existing condition” of his fatal trajectory towards the ground of which the man initiated. We do not state the firefighter killed him, instead he simply allows him to die (Huddle, 2012, p. 261).
Resolutions
Moral Principles. With consideration of Andrea’s case I feel her parents are able to consent for her in terms of what they would see benefit in for their daughter’s situation. As well I believe in the case of Andrea that she was expected to pass, as evidence by the “last ditch effort” of an experimental antibiotic, the doctor and parents felt DNR status was appropriate for their daughter and she did rapidly decline. In this case I feel based on mercy to end her suffering it would be morally correct for the parents to wish for active euthanasia for their daughter. Her outcome would not have changed. Instead we can argue mercy and non-maleficence in the case that her two days of heart failure and labour breathing were unnecessary.
Moral Theories. Considering the theory of Utilitarianism we can argue that the morally right decision would be to maximizing benefit through ending suffering (Pro) and minimizing harm by doing so quickly to not allow for the unnecessary suffering Andrea felt the last two days of her life (con) (Wilfred & Gedge, 2012, p. xxi). Utilitarianism would also consider her parents suffering as well and allow the legalization of Euthanasia based on the premise’s similar to Andrea’s (Wilfred & Gedge, 2012, p. xxi). The first formulation of Kantian theory asks you to consider what would happen if this were applied to all similar situations without the consideration of consequences (Wilfred & Gedge, 2012, pp. xxvi-xxvii). Legalizing euthanasia would bring respect and dignity to the patient as well as treating them as a person not an object (i.e. their disease) (Wilfred & Gedge, 2012, p. xxvii). The third formulation of Kantian theory would also support the legalization of euthanasia through respecting the wishes of Andrea’s parents as well as allowing Andrea’s dignity to remain intact by allowing her a peaceful passing (Wilfred & Gedge, 2012, p. xxviii). When examining support for and against euthanasia we see the very persuasive argument of violating physician’s autonomy and justice through legalization of euthanasia. Legalization would not force the physician to preform instead it would allow the physician to explore who they want to be much like virtue ethics considers. A physician can refuse to perform abortions, these similar circumstances would be applied through euthanasia. We can then apply the Kantian formulation to the physician by allowing his autonomy and dignity and allowing him to choose who he wants to be as a physician through that of virtue ethics (Wilfred & Gedge, 2012, p. xxxiii). Many doctors may say they became a doctor with the intention of helping others. Doctors may see this as the greatest act of altruism possible and can bring them great happiness knowing they helped another in their greatest time of need.
Recommendations.
I would support active euthanasia being law in Canada for cases much like Andreas. If active euthanasia were used in this case when her parents had considered it, it would have not only benefited Andrea by ways of a peaceful death, but it would have the additional benefit of also relieving some of the emotional pain and agony suffered by her parents in her final days as evidence by her father stating “watching your own child die is worse than dying yourself”. My position on this issue is perfectly summed up through a quote from Battin (1987). Battin (1987) found:
“Where possible, one ought to relieve the pain or suffering of another person, when it does not [undermine] that person’s wishes, where one can do so without undue costs to [themselves], … where the pain or suffering itself is not necessary …, and where the pain or suffering can be relieved…” (p. 321).
From personal experience I know that being in a situation where a loved one is suffering can change your opinion. As Battin (1987) might suggest, what would you want if it were you or a loved one suffering, wouldn’t you want the ability for your opinion and wishes to be heard? Legalizing active euthanasia for terminally ill and chronically suffering patients allows them the right to have their wishes heard. It does not mean that all terminally ill patients would be persuaded towards active euthanasia, it would just give a last option and one last choice for those who likely feel they no longer have that ability.
References
Battin M.P. (1987). Euthanasia: the fundamental issues In E. Gedge & W. Waluchow (Eds.), Readings in health care ethics. 321-343. Ontario: Broadview Press.
Callahan, D. (1992) When self-determination runs amok. In E. Gedge & W. Waluchow (Eds.), Readings in health care ethics. 344-348. Ontario: Broadview Press.
Harrison C., Kenny N.P., Sidarous M., & Rowell M. (1997) Bioethics for Clinicians: Involving Children in Medical Decisions. In E. Gedge & W. Waluchow (Eds.), Readings in health care ethics. 93-97. Ontario: Broadview Press. 93-97.
Huddle, T. S. (2012). Moral fiction or moral fact? The distinction between doing and allowing in medical ethics. Bioethics, 27(5), 257-262.
McTavish C. (2013). PHIL 335 Study Guide [Revision 2]. Athabasca, AB: Athabasca University. Retrieved March 4, 2016, from http://gsa.lms.athabascau.ca/course/view.php?id=84
Palliative. (n.d.). The American Heritage® Science Dictionary. Retrieved March 05, 2016 from Dictionary.com website http://dictionary.reference.com/browse/palliative
Puzio, S. (2012) Personal Communication.
Wilfred W.J., & Gedge E.. (2012). Introduction: ethical resources for decision-making. In E. Gedge & W. Waluchow (Eds.), Readings in health care ethics. Xi-xlv. Ontario: Broadview Press.
