Bioethics Luiss PPE Program Class 14 April 10 2015 Topics for - - PowerPoint PPT Presentation

Bioethics

Luiss PPE Program Class 14 April 10 2015

Topics for today’s Class

Suicide Assisted Suicide and Voluntary Euthanasia Active and Passive Euthansia Slippery Slope Argument

Suicide and the Classics

Diogenes Laertius: “The sage leads himself rationally (eulogos) out of life, namely on behalf of fatherland or friends, also when he suffers from pain which is too fierce, mutilations or incurable diseases” Is there any significant moral difference between these two sets of voluntary deaths? We can easily recognize some voluntary deaths as morally excellent, because prudent and courageous, it is likely that in other cases morality counsels its own silence.

Hobbes on suicide

There is no plausible secular argument to show that suicide is a subset of

• murder. There cannot be, since there is convincing argument to suggest that

“self-murder” is an oxymoron: injustice to oneself is an incoherent idea, as Hobbes, who explained murder as a species of injustice, demonstrated: Whatever is done to man, conformable to his own Will signified to the doer, is no Injury to him. For if he that doeth it, hath not passed away his original right to do what he pleases, by some Antecedent Covenant, there is not breach of Covenant; and therefore no injury done him. (1845: 137)

Hume on Suicide

That Suicide may often be consistent with interest and with our duty to ourselves, no one can question, who allows, that age, sickness, or misfortune may render life a burthen, and make it worse even than annihilation. If Suicide be supposed a crime, it is only cowardice can impel us to it. If it be no crime, both prudence and courage should engage us to rid ourselves at once of existence, when it becomes a

• burthen. It is the only way, that we can then be useful to society, by setting an example, which, if

imitated, would preserve to every one his chance for happiness in life, and would effectually free him from all danger of misery.

Kant on Suicide

To annihilate the subject of morality in one's person is to root out the existence

• f morality itself from the world as far as one can, even though morality is an

end in itself. Consequently, disposing of oneself as a mere means to some discretionary end is debasing humanity in one's person… (Kant 423) For Kant, our rational wills are the source of our moral duty, and it is therefore a kind of practical contradiction to suppose that the same will can permissibly destroy the very body that carries out its volitions and choices. Given the distinctive worth of an autonomous rational will, suicide is an attack on the very source of moral authority. (Cholbi, Suicide, Stanford Encyclopedia)

Confusions and Prejudice about suicide

Suicide is the key concept in any broadly philosophical discussion of voluntary death Suicide still carries a strongly negative subtext, and on the whole, we exhibit a greater willingness to categorize self-killings intended to avoid one's just deserts as suicides than self-killings intended to benefit others (Beauchamp & Childress 1983, 93–94). Conceptual confusion surrounding the morality of voluntary death, derived in the main from traditional religious attitudes, thwarts mature evaluation of suicide, assisted suicide, and euthanasia.

Causing one’s death

Is causing oneself to die sufficient to say that a person is suicidal? Conversely, can a person can be suicidal when she only sets the circumstances that would lead to her death?

A definition of Suicide

A person S's behavior B is suicidal iff 1. S believed that B, or some causal consequence of B, would make her death at least highly likely, and 2. S intended to die by engaging in B. This account renders the notion of suicide as self-inflicted attempted death more precise, but it is not unproblematic.

Is Suicide a form of Self-murder?

Pro Argument: Suicide needs special justification simply because it is a form of killing, all killing being wrong. Contra Argument: Suicide is not among the cases of killings that count as murders and are wrong. Suicide lacks the essential element which allows us to include it among the subset of killings that are wrong.

Two cases

Eluana Englaro and Terry Schiavo

Eluana Englaro

Eluana Englaro (25 November 1970 – 9 February 2009): entered a persistent vegetative state on 18 January 1992, following a car accident. Shortly after her accident, medical staff began feeding Englaro with a feeding tube, but her father "fought to have her feeding tube removed, saying it would be a dignified end to his daughter's life. He said that before the crash his daughter visited a friend who was in a coma and told him she didn't want the same thing to happen to her if she were ever in the same state." The authorities refused his request, but the decision was finally reversed in 2009, after she had spent seventeen years in the coma.

Therri Schiavo

Terri Schiavo collapsed in her St. Petersburg, Florida, home in full cardiac arrest on February 25, 1990. She suffered massive brain damage due tolack of oxygen and, after two and a half months in a coma, her diagnosis was changed to vegetative state. For the next two years doctors attempted speech and physical therapy and other experimental therapy, hoping to return her to a state of awareness. In 1998 Schiavo's husband, Michael, petitioned the Sixth Circuit Court of Florida (Pinellas County), to remove her feeding tube pursuant to Florida Statutes Section 765.401(3).[3] He was

• pposed by Terri's parents, Robert and Mary Schindler, who argued that she was conscious. The court determined that

she would not wish to continue life-prolonging measures,[4] and on April 24, 2001, her feeding tube was removed for the first time, only to be reinserted several days later. On February 25, 2005, a Pinellas County judge ordered the removal

• f Terri Schiavo's feeding tube. Several appeals and federal government intervention followed, which included U.S.

President George W. Bush returning to Washington D.C. to sign legislation designed to keep her alive. After all attempts at appeals through the federal court system upheld the original decision to remove the feeding tube, staff at the Pinellas Park hospice facility where Terri was being cared for disconnected the feeding tube on March 18, 2005. Terri died on March 31, 2005.

Assisted Suicide and Euthanasia

Both these modes of voluntary death are morally derivative from suicide, because if there is compelling reason to provide aid in dying, either indirectly or directly, it stems from the sovereign role of the dying patient in determining that their life project is to be completed. The strength of the person’s reasons for terminating life through suicide provides whatever reasons there are for helping. Respect for the patient’s authentic desires and compassion for their suffering provide the moral case for assisted suicide and euthanasia: they establish a claim – usually stated as a moral right – to aid-in-dying, and provide the basis for a charge that any legal structure which impedes access to aid is cruel because it perpetuates pointless unwanted suffering.

Argument from Equal Liberty

If it is unjust to discriminate against those who are terminally ill but not machine-dependent, then it is equally unjust to discriminate against a subset of them, namely those who are disabled to a point where suicide is not a realizable

• ption but who nonetheless strongly desire a swift death.

Two rulings

On March 6, 1996, the Ninth Circuit Court of Appeals, sitting in San Francisco, found that liberty interests based on the 14th Amendment made American law forbidding physician-assisted suicide unconstitutional. Of the 11 judges, 8 concurred in the judgment that there is a constitutionally protected liberty in determining the time and manner of one’s death. On April 2, 1996, the Second Circuit Court of Appeals, sitting in New York, came to the same conclusion for slightly different reasons. Relying on the equal protection clause of the 14th Amendment, the court argued that there was no difference between withdrawal of life-support systems and the prescription of drugs to cause death.

Argument from Reasonableness

The terminally ill who see suicide as a means of exercising sovereign control

• ver the timing of their death may do so for different reasons.

Access to those reasons could only come through a deeper knowledge of their life project and how it was conscientiously shaped. There is no guarantee that their aspirations are easily accessed by those who see them professionally, and it is not uncommon for members of the same family to be in dispute about choices near death.

Rachels on Active and Passive Euthanasia

The distinction between active and passive euthanasia is thought to be crucial for medical

• ethics. The idea is that it is permissible, at least in some cases, to withhold treatment and

allow a patient to die, but it is never permissible to take any direct action designed to kill the patient. American Medical Association 1973: “The intentional termination of the life of one human being by another -mercy killing - is contrary to that for which the medical profession stands and is contrary to the policy of the American Medical Association. 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. The advice and judgment of the physician should be freely available to the patient and/or his immediate family.”

Against the distinction

Case # 1 A patient who is dying of incurable cancer is in terrible pain, which can no longer be satisfactorily alleviated. He is certain to die within a few days, even if present treatment is continued, but he does not want to go on living for those days since the pain is unbearable. So he asks the doctor for an end to it, and his family joins in the request. Suppose the doctor agrees to withhold treatment, as the conventional doctrine says he may. The justification for his doing so is that the patient is in terrible agony, and since he is going to die anyway, it would he wrong to prolong his suffering needlessly.

Against the distinction

Notice this: It may take the patient longer to die, and so he may suffer more than he would if . direct action were taken and a lethal injection given. This fact provides strong reason for thinking that, once the initial decision not to prolong his agony has been made active euthanasia is actually preferable to passive euthanasia, rather than the reverse. To say otherwise is to endorse the option that leads to more suffering rather than less, and is contrary to the humanitarian impulse that prompts the decision not to prolong his life in the first place.

Against the Distinction

Case #2. In the United States about one in 600 babies is born with Down's syndrome. Most of these babies are otherwise healthy. Some, however, are born with congenital defects such as intestinal obstructions that require operations if they are to live. Sometimes, the parents and the doctor will decide not to operate, and let the infant die. Anthony Shaw describes what happens then: “When surgery is denied the doctor must try to keep the infant from suffering while natural forces sap the baby's life away. As a surgeon whose natural inclination is to use the scalpel to fight off death, standing by and watching a salvageable baby die is the most emotionally exhausting experience I know. It is easy at a conference, in a theoretical discussion, to decide that such infants should be allowed to die. It is altogether different to stand-by in the nursery and watch as dehydration and infection wither a tiny being over hours and days. This is a terrible

• rdeal for me and the hospital staff - much more so than for the parents who never set

foot in the nursery.

The Slippery Slope Argument

Slippery slope arguments can be used in the context of any discussion whatsoever, but if you are asked to give an example, the odds are that the example which first comes to your mind will be one from a bioethical discussion.

Slippery Slope: An Example

Prenatal diagnostics is wrong in principle, if abortion is the only thing we can do when a genetic defect is found. First a suspicion of Huntington’s disease or cystic fibrosis will be counted as a good reason for abortion. Then it will be diabetes, sickle cell anemia, Down syndrome, then a club-foot, a harelip, myopia, color blindness, an extra Y chromosome, left-handedness, and finally skin color. It will be argued that it is in the interest of the future child itself not to be born. But how can we decide that someone’s life will not be worth living? People have no right to decide that the life of a handicapped person has no value. To do so is a violation of the basic principle of equality. If we allow ourselves any exceptions to that principle, handicapped people will come to be seen as the products of parental negligence. People will say to them: “Why are you here? You should have been aborted.” And if these people are consistent, they will in the end believe that the lives of these people should still, in their own interest, be terminated.

The form of the Argument

• The discussion presupposes a status quo position, in which people hold each other, or are held by

legal authority, to certain norms of behavior, prohibiting A.

• It is proposed to move from the status quo position to a new one, which I will call the top of the

slope, in which A will be considered acceptable or be permitted.

• The opponents of the proposal do not question the acceptability of the top position directly. They

neither assume that actions of type A are offensive as such, nor necessarily should suggest that such actions are to be avoided because of their negative consequences

• Instead, the opponents argue that a movement will not stop before we have reached the bottom of

the slope; unpacking the metaphor, it is alleged that a causal mechanism exists which, once we accept actions of type A, will cause us to accept actions of type N as well. Note that in the paradigmatic form

• f the slippery slope argument it is not the A-type action itself which is supposed to have negative

consequences, but rather the decision to consider such actions acceptable.

• The causal mechanism referred to has the character of a chain reaction: once we accept A, we will

predictably accept B as well, this will cause us to accept C, and so on, until eventually we come to accept N.

Causal and Logical Forms of the Argument

The logical form would simply consist of pointing out that, once we accept A, we are rationally committed to accepting B, C, and eventually N. But in practice this logical form is almost always incorporated into a prediction. The opponents assume that even the supporters of the proposal agree that actions of type N are beyond the pale, either for intrinsic reasons, or because of their bad consequences, or both. Most of the time it is silently presupposed that actions of type N, once they are accepted, will be done more often. However, even if this is not the case, it may be alleged that the fact that these bad actions are not only done, but also tolerated, is a bad thing in itself. On the other hand, the opponents may also argue that, whether or not actions of type N will be accepted, they will in any case be done more often than they are done at present, and that is what should deter us from accepting A in the first place.

Appeal to Precedent

It is again conceded that A has an innocent look. However, it is argued that,

• nce we accept A, we have no reason to reject B, which in all relevant respects

resembles A. But B is clearly unacceptable. This is not a paradigmatic slippery slope argument, because it does not make any predictions about whether, once we accept A, we will in fact accept B. The claim is the more limited one that, if we accept A, we are rationally committed to accepting B.

Slope by Reason

The best-known use of this argument is in the context of abortion. If one considers the killing of a zygote to be acceptable, there is no reason to prohibit the killing of an embryo 14 days after conception. If that is acceptable, there is no reason to be concerned about the killing of a fetus of three months – and so on. As the development from zygote to child

• ccurs without any sudden jumps, once you have denied protection to the zygote, there is

no point at which you can reasonably think it imperative to protect the developing human

• being. Viability will not do, because it depends on the skills of doctors; nor will birth,

which after all doesn’t involve any change in the child, but only in its environment. This argument is similar in form to the one discussed in the previous section: it simply repeats the appeal to a precedent, until a clearly pernicious one is reached. If you permit A, you are committed to permitting B; if you permit B, you are committed to permitting C,

• etc. Therefore, if you permit A, you are committed to permitting N, which clearly is

wrong.

If the appeal to a pernicious precedent is a valid form of argument – in the weak sense of validity which allows for the possibility of defeat – then the logical slippery slope argument, it seems, cannot be an invalid one. However, the requirement itself rests on a fallacy, known from ancient times as the Sophism of the Heap (Sorites). Consider any person with normal hair growth. Take away

• ne of her hairs. That wouldn’t make her bald, would it? Take away another hair. How can
• ne hair make the difference between a bald person and a non-bald person? It cannot. So

we take away another hair, and another one, etc. At the end of the process she has no hair

• left. Still, we are not allowed to call her bald, for we couldn’t meet the requirement of

pinpointing the exact moment at which she joined the class of bald persons. (It may be

• bjected that only a person with no hair at all is a bald person, strictly speaking, but that

is not how we normally use the word.)

References

Brian Stoffell , Voluntary Euthanasia, Suicide, and Physician-assisted Suicide, in Kuhse and Singer 312- 320. Govert den Hartogh, The Slippery Slope Argument, in Kuhse and Singer 321- 332. James Rachels, “Active and Passive Euthanasia.” New England Journal of Medicine 292, no. 2 (1975): 78-80.