I. Preliminaries II. Important Distinctions III. The Combinations

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1 I. Preliminaries A. Death: the primary criteria used to determine whether a person is alive is to determine whether there is any detectable brain function; if so, then the person is not dead; if there is no detectable brain function, the person is dead. -even if there is some slight non-conscious brain function, the person is to be considered living. -lack of blood circulation for five to ten minutes will end brain-functioning, thereby ending the life of the person. B. Permanent Vegetative State (PVS): (1) loss of all cerebral cortex function (where higher-level nervous activity takes place, e.g. cognition) (2) not dead because of retention of good brain stem function (e.g. respiratory and heart rate, facial reflexes and muscle control, gag reflex, swallowing ability) (3) not conscious and never will be. (4) Because the person is not conscious, he or she cannot feel pain. (5) Goes through sleeping and waking cycles in which eyes open and close; said to be awake but not conscious. C. Coma: (1) only brain activity is poor brain stem function; so not dead. (2) not conscious and asleep. (3) tend not to live as long as PVS cases, because of poor brain-stem function. II. Important Distinctions A. Active vs. Passive Euthanasia: Killing vs. Letting Die (1) Active: When a patient is killed, usually by lethal injection. (2) Passive: When treatment is stopped (or simply not started) allowing a person to die. (A common medical practice carried our by ~96% of doctors.) B. Voluntary vs. Non-voluntary Euthanasia (1) Voluntary: The person whose life is at issue knowingly and freely decides to either be killed or to be left to die by the withholding treatment. (2) Non-voluntary: When a patient is unable to request her own death and the decision is made by others. (e.g. infants, small children, comatose patients, patients in permanent vegetative states, mentally incompetent patients such as those with Alzheimer's). C. Withholding Ordinary Measures vs. Withholding Extraordinary Measures (1) Withholding ordinary measures: when treatment that has good potential to benefit the patient is withheld; such treatment has a reasonable chance to cure or ameliorate a life-threatening condition. (2) Withholding extraordinary measures: when treatment that has little or no prospect of benefitting the patient is withheld; such treatment is considered ineffective and excessively burdensome. III. The Combinations A. Types of Voluntary Euthanasia (1) active, voluntary euthanasia: when a competent patient requests to be killed by a doctor.

2 (2) passive, voluntary euthanasia by withholding extraordinary measures: when a patient requests that a treatment which has little or no prospect of benefitting her be withheld so that she may die without needlessly wasting resources. (3) passive, voluntary euthanasia by withholding ordinary measures: when a patient requests that a treatment which has good prospects of improving or prolonging life is withheld so that she may die. B. Types of non-voluntary Euthanasia (1) active, non-voluntary euthanasia: when a patient who cannot choose death herself is killed at the bequest of others, most often family. (2) passive, non-voluntary euthanasia by withholding extraordinary measures: when a patient who cannot choose death herself is withheld treatment with little or no hope of improving her condition so that she may die. (3) passive, non-voluntary euthanasia by withholding ordinary measures: when a patient who cannot choose death herself is withheld treatment that has good prospects of improving her condition so that she may die. IV. Physician Assisted Suicide and the Principle of Double-Effect Physician Assisted Suicide: When the doctor provides the means by which a patient will commit suicide with full knowledge of the patient s intentions. Technically, not a form of euthanasia. This is taken by proponents to be a good solution to the debate on active euthanasia. Since one person is not killing another, there is no issue of murder. Proponents argue that since terminally ill patients have a right to end their own suffering, they can enlist the help of their doctors to do so. Opponents argue that patients do not have a right to take their own lives and assisting such an activity is not the role of a doctor. Dr. Jack Kevorkian is the most famous practitioner of physician assisted suicide. Kevorkian was charged with two counts of murder but was subsequently acquitted. He was even acquitted when he was prosecuted for violating state laws banning physician assisted suicide. It was only when Kevorkian actively euthanized a patient that he was convicted in a court, this time for second-degree murder. The Relevancy of the Principle of Double-Effect: It is not considered physician assisted suicide if the doctor provides pain medication with the intention of easing pain, but the patient dies or uses the medication to commit suicide, even if the doctor foresees such possible consequences. Whether such an action is morally permissible depends upon whether the principle of double effect is a legitimate principle. According to this principle, if one administers a pain killer while intending to produce a good effect, such as relieving pain, then one has not done something morally impermissible, even though one is fully aware that a bad effect, such as death or abuse, may also be the consequence of one s actions. V. Euthanasia and the Law A. The United States: Active euthanasia is currently illegal in the USA, but physician assisted suicide is currently legal in Oregon (though Dr. Kervorkian was exonerated on three occasions in Michigan). The Supreme Court, while not acknowledging a constitutional right to die, have made euthanasia an issue for the states. -Often times, people who commit mercy killings are sentenced very lightly or simply not convicted. (e.g. A man shot to death his terminally ill and suffering wife in a Chicago hospital

3 but the jury at his murder trial refused to convict him of anything even though it should have been an open and shut case). -Passive voluntary and involuntary euthanasia are common and largely uncontroversial medical practices. B. The Netherlands: Active Euthanasia is legal in the Netherlands provided the following conditions are met: (1) Voluntariness: The request of the patient must be made entirely of the patient s own free will without any pressure from others. (2) Informed and competent: The patient must be informed of all the alternatives and be capable of contemplating them. (3) Certainty: The patient must have a lasting longing for death; requests made on impulse or based on temporary depression are not considered. (4) Unacceptable Suffering: The patient must experience suffering as perpetual, unbearable and hopeless. (5) Consultation: The doctor must consult another physician who has faced at least one case of euthanasia before. VI. Euthanasia and Religion A. Monotheistic Religions: Islam, Judaism, and Christianity have for the most part been traditionally opposed to active euthanasia, though there has been a significant number of traditional and contemporary Christian theologians and philosophers who advocate it (St. Thomas More, R.M. Hare and Daniel Maguire) B. The Sixth Commandment and the Golden Rule: an argument from James Rachels -James Rachels observes that Theologians generally agree that the Sixth Commandment is to be interpreted as Thou shalt not murder not as Thou shalt not kill. So while no one would question whether active euthanasia is killing, one would need to argue that it is murder or a wrongful killing. Hence the Sixth Commandment alone cannot rule out active euthanasia. But, Rachels continues, if the golden rule has any validity, euthanasia ought to be considered permissible on occasion to Christians. For example, if a physician, while witnessing the unremitting pain of a patient, thinks to himself I would want to die if I were in that position, then it would seem to follow from the golden rule that it would be permissible for the physician to euthanize the patient if the patient requested it. This is bolstered, says Rachels, particularly if we keep in mind the Bible s exhortations to Mercy. C. Others: Buddhists, Shintos, and Confucians believe, as did Ancient Greeks and Romans, that active euthanasia is morally permissible. VII. Other Facts A. Doctors -The AMA and the hippocratic oath both prohibit active euthanasia and physician assisted suicide. -61% of the general public are in favor of physician assisted suicide. -46% of oncologists agree with physician assisted suicide in cases of unremitting pain

4 VIII. Utilitarianism, Kantianism and Euthanasia A. Voluntariness: concerns about voluntariness with regard to euthanasia are concerns about how much freedom and control a patient should have over his or her own death. Those who emphasize patient voluntariness want patients to have at least some say in deciding how they want to die; those who are not concerned with patient voluntariness believe that the patient s own desires about they want to die are irrelevant with regard to how his or her life will actually end. 1) Utlilitarianism and Voluntariness: voluntariness matters morally only to the extent that it affects human happiness and welfare. a) act utilitarianism: a patient s voluntariness should probably be limited if he or she is ignorant of the availability of services, support and money that is, in fact, available. For example, if a patient learns that she has cancer and immediately wants to be euthanized, her voluntariness should probably be overridden if treatment would give her a good chance of survival. Presumably, successfully treating a curable type of cancer would maximize the happiness of the patient and her family in the long run. b) rule utilitarianism: rule utilitarians would have to determine which policy regarding patient voluntariness would maximize happiness if implemented in society at large. Presumably, a policy of giving a patient free reign over how she wants to die would not maximize happiness, since such a policy would always undermine the opinion of physicians or those who are most informed about the prospects of survival and the success of treatment. On the other hand, it seems highly unlikely that a policy whereby patients never had a say in whether they wanted to be euthanized would maximize happiness. A moderate position, in which patient choices could be overridden by medical experts when they decide that euthanasia would not be in the patient s best interest, would seem to be most likely to pass muster on a rule utilitarian analysis. 2) Kantianism and voluntariness: the Kantian respects the capacity of a person to govern his own life and make his own decisions. Hence, the Kantian would respect the wishes of a fully informed, mentally competent patient who wanted to be euthanized. Clearly, though, if a patient does not know all of her options, her capacity to exercise her autonomy is limited; in such a case, if the person wants to be euthanized, her own choice should be overridden until she is fully informed. Overriding the choice, here, would not be undermining her autonomy but would be an attempt to further it by making sure she has all the relevant information. Moreover, if a patient with a good chance of survival still wants to be euthanized, she most likely would not be considered mentally competent, in which case her own well-being should be placed into the hands of others. (We do something similar with children, the mentally retarded, Alzheimer's patients etc.) B. Active and Passive Euthanasia: Is there any moral difference between active and passive euthanasia? Is active euthanasia more morally problematic than passive euthanasia? If so, why? If not, why not? 1. Utilitarianism a) act utilitarianism: only looks at the consequences of the action, not the nature of the action itself. Hence, the utilitarian will be unfazed by the claim that active euthanasia is wrong because it is killing, whereas passive euthanasia is okay because it is merely letting someone die. Indeed, if passively euthanizing a patient by withholding a life-prolonging treatment leads to more overall suffering than would actively euthanizing the patient, killing the patient at his request would be the morally obligatory action, while letting someone die would be

5 impermissible. In general, if passively or actively euthanizing a patient does not make a difference in terms of the total amount of happiness, then it would not matter whether death was caused by lethal injection or simply by terminating a life-prolonging treatment. b) rule utilitarianism: would look at the consequences of implementing a policy of active euthanasia. Would a policy that allowed active euthanasia in all terminal cases maximize happiness? Or in some cases but not others? Or only in rare cases? Or never? Of concern would be how much abuse would follow from a policy that allowed active euthanasia, and how well the authorities could curb such abuse. For example, would it ever come about that some patients were non-voluntarily euthanized? If so, would such occurrences outweigh the reduction of overall suffering that a policy allowing active euthanasia in some cases would accomplish? The matter of abuse is an empirical matter. It is not enough to say I ll bet abuse would happen or to simply ask What if abuses happen?. For the most part, utilitarianism would seem to support active euthanasia in some--or perhaps many--cases, since it would clearly reduce the suffering of patients and the families who watch them suffer. Hence, the burden of proof is on the opponent to show that abuses do or are very likely to occur, and the harm of such abuses would outweigh the good of a policy allowing active euthanasia. 2. Kantianism: a Kantian might argue that respecting a person s right to die should make irrelevant some of the potential abuse of implementing a policy of active euthanasia that worried the utilitarian. Clearly, if such abuse involved actively euthanizing the patient against the patient s wishes, then the Kantian would be opposed (since that would be a violation of the patient s autonomy). But the Kantian, since he is concerned with patient autonomy, would be able to justify voluntary active euthanasia even if the patient s physician, family or community would be strongly opposed. Or take for example the extremely unlikely but conceivable case where a medical breakthrough occurs after we actively euthanize someone, but most likely before they would have died if we never had actively euthanized them. One might be able to argue, on utilitarian grounds, that actively euthanizing the patient was the wrong choice, since continuing treatment would have ultimately maximized happiness. The Kantian could object by claiming that the overriding consideration here is the respect of the patient s autonomy, not the consequences of the actions. IX. Cases A. A paradigmatic case of voluntary, active euthanasia Albert A., a hospital patient, was dying of cancer which had spread throughout his body. The intense pain could no longer be controlled. Every four hours he would be given a painkiller to which he had built up a tolerance that would alleviate his pain for a matter of minutes. Albert knew he was going to die anyway, for the cancer could not be cured. He did not want to linger in agony, so he asked his doctor to give him a lethal injection to end his life without further suffering. Albert s family supported this request. (1) The act utilitarian must ask: would administering the drug maximize the happiness, or minimize the unhappiness, of those affected by the action? -abstracting away from all legal cosequences for the doctor and the hospital, this would be an easy case for the utilitarian: Albert s doctor would minimize unhappiness by euthanizing Albert. The only thing that might prevent the utilitarian from concluding this would be if we situated the action in a forbidding legal context in which Albert s physician would be tried for murder and

6 his hospital is sued. But this really misses the point: that there is no in principle act-utilitarian objection to active euthanasia. (2) The rule utilitarian Would the practice of euthanizing a terminally ill and suffering patient upon that patient s request maximize happiness within a society? ---rule (1): Euthanize terminally ill and suffering patients upon request when loved ones are supportive. -Might there be too much abuse if such a policy were implemented? Would we slide down a slippery slope? Might family members begin pressuring ill patients to opt for euthanasia to avoid paying expenses of treatment-- and if so, would this be negative? ---rule (2): Do not euthanize terminally ill and suffering patients upon request, even when loved ones are supportive. -Patients would continue to suffer miserably until death, and family members would continue to watch in utter horror and despair. (3) The Kantian *Kant himself seemed to think suicide would be wrong, but does is system really rule out euthanasia? --(a) The first formulation of the categorical imperative --Would willing as universal law that terminally ill patients be euthanized upon request be contradictory or undermine the physician s ability to euthanize the patient in this case? ---> I don t see why. --(b) The second formulation: would a physician s euthanizing a terminally ill patient be disregarding the patients own interests, goals and desires in favor of his own interests, goals and desires? Most definitely not--> active euthanasia is morally permissible. --(c) Might it be an imperfect or meritorious duty? --Try willing this universally: Never contribute to the well-being of another or assist her when in need. -Unlike the maxim make false promises we could imagine a world where people followed this maxim; however, one could not will this as a universal law because it would contradict one s own will to have others assist him at times. Hence, contributing to the well-being of another and assisting others in need is an imperfect duty. We are not required to act out of this duty at all times, as we would the duty not to make false promises, but we are required to make some contribution to the well-being of others and assist them when in need. -Now, try willing this universally: always refuse a terminally ill patient s request for euthanasia. If the physician were terminally ill and in a constant and unbearable state of suffering, would his will contradict the universal law just willed? Most likely, yes. If so, then the duty to euthanize the patient is meritorious, or one that is deserving of honor and esteem--it would be a morally praiseworthy act. B. Other cases of active voluntary euthanasia Barbara B. was a multiple amputee and diabetic in constant pain who was told that she could live for only a few more months. She begged her husband to kill her, and he did, by electrocution. The husband was charged with murder and was convicted. On sentencing day the judge wept.

7 Mr. B. never wavered in his opinion that he had done the right thing, and he said that his act was an act of love. The driver of a gas truck was in an accident in which his tanker overturned and immediately caught fire. He was trapped in the cab and could not be freed. He therefore besought one of the bystanders who had a gun to kill him by shooting him in the head so that he would not roast to death. The bystander obliged. X. Brandt on Killing and Killing Injuriously A. Killing vs. Killing Injuriously: Richard Brandt (1910-) argues that we should not accept the principle that we should not to kill an innocent human being except in justifiable self-defense. Rather, he thinks that there is a more fundamental duty of not causing injury, and that one can kill without causing injury. Predictably, for Brandt, active euthanasia, if carried out according to basic restrictions, is a case of killing without injury and is therefore morally permissible. According to Brandt, one is not causing another injury if he is treating that person in a way in which that person would rationally want to be treated. 1. Cases of killing without injury (a) if someone is roasting to death and has made clear that he wants to die, then shooting him, according to Brandt, is not causing him injury. It is not causing injury precisely because he is relieving pain. Presumably he is thereby treating the person dying in a way that he would rationally want to be treated. (b) if someone is unconscious and it is known that he will never regain consciousness, then, according to Brandt, if we have good reason to believe that this person would want to be euthanized, then we could kill him. This would again be killing without injury because the person is in a condition that exempts him from or places him beyond injury. B. The Moral Force of Patient Request: suppose a terminally ill patient who is suffering tremendously but is being given treatment that extend his life requests that such treatment be continued even though he will prolong unnecessary and unbearable suffering. Most, if not all, of us would respect such a request, even though we might not understand it and consider it to be irrational. Brandt asks why the patient s expressed wishes should carry moral force in this case-- when he is behaving irrationally and causing himself needless suffering-- but would carry no moral force when a patient asks to be actively euthanized in a rational and comprehensible effort to end his pain. -According to Brandt, since the expressed wishes of a patient carry moral force, and killing in this case would non-injurious, we are permitted to actively euthanize tha patient.