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‘’ Euthanasia and Physician- Assisted Suicide

For fifteen years, Terri Schiavo existed between life and death in that shadow land called a persistent vegetative state, a place where she was wakeful but without awareness or any purposeful behavior. Severe brain damage had left her there, with vir- tually no chance of recovery. And all the while, a storm of caustic debate swirled around her, reach- ing its greatest strength in the last few days before her death on March 31, 2005. In 1990 her heart had stopped briefly because of a chemical imbalance, leaving her in that twilight state, kept alive by a feeding tube. She had left no living will, no written record of her wishes should she become indefinitely incapacitated. Her husband, Michael Schiavo, insisted that Terri had told him once that she would prefer death to being kept alive with machines. Her parents rejected his claim and demanded that Terri be kept alive, holding out hope that with proper care she might recover.

The battle between Michael Schiavo and Terri’s parents raged on in the courts for years. Again and again, state and federal courts sided with the hus- band, while the U.S. Supreme Court repeatedly refused to hear the case. In the final days before Terri died, President George W. Bush, the U.S. Con- gress, the governor of Florida (where she lived), and Florida legislators weighed in on the controversy, supporting Terri’s parents.

Finally, a judge allowed the feeding tube to be removed, and Terri Schiavo, age forty- one, died thirteen days later. The parents called the removal “judicial homicide.” A Vatican official called it “an attack against God.”1

So it goes with all public debates on the moral permissibility of euthanasia. Passions rise, claims and counterclaims collide, and stakes are high. In the balance are issues of life and death, science and religion, murder and mercy. The tragic end of Terri Schiavo is only the most dramatic (and dramatized) case in a series of tragic ends that turned into widely publicized moral battlegrounds (see the box “The Death of Karen Ann Quinlan”). The moral ques- tions it incited are typical of such cases: Was remov- ing Terri Schiavo’s feeding tube really a case of murder? Or was it a morally permissible act allow- ing her to die with dignity and escape her bleak condition? What if instead of stopping the tube feeding, her doctors had never started it because they deemed her situation hopeless? Would that have been murder— or a permissible act of mercy? Or suppose that soon after Schiavo collapsed, her doctors had decided to give her a lethal injection? Would such an act have been morally wrong? What if Schiavo had left a living will that clearly specified that she did not want to be kept alive by any means if she fell into a persistent vegetative state? Would withdrawing the feeding tube or giving her a lethal injection then have been morally acceptable?

Of course, in every instance of euthanasia there are plenty of nonmoral questions too— primarily legal, judicial, medical, scientific, and political. (In the Schiavo case, for example, the moral ques- tions arose side by side with what most informed observers saw as the real issue: Who, if anyone, had the legal right to decide for Schiavo what was to become of her?) But these nonmoral concerns





preserved in the Greek roots of euthanasia, which literally means “easy death.” Euthanasia makes sense to many people because they believe that a quick and painless death would be preferable to a slow and painful dying (such as the kind that some terminal cancer patients endure) or a long, vegeta- tive sleep without a chance for a meaningful life.

As you might expect, the moral permissibility of euthanasia depends heavily on the consent of the patient (the person whose death is being con- sidered). Moral philosophers therefore distinguish between euthanasia that is voluntary, nonvolun- tary, and involuntary. In voluntary euthanasia, the patient requests or agrees to the act. She may make the request in person or leave instructions to be followed in case she becomes incapacitated. Such instructions are usually in the form of an advance directive (for example, a living will), a legal docu- ment allowing physicians to withhold or withdraw treatments if a patient becomes terminally ill and unable to express her wishes. For any voluntary euthanasia request to be valid, the patient at the time of the request must be competent— that is, capable of making an informed, rational choice. In nonvoluntary euthanasia, others besides the patient (family or physicians, for example) choose euthanasia for her because she is not competent (due to illness or injury) and has left no instruc- tions regarding her end- of- life preferences. Eutha- nasia performed on infants and small children is, of course, nonvoluntary. In involuntary euthana- sia, the act is carried out against the wishes of the patient and is therefore illegal and widely regarded as immoral.

People also draw a distinction between active and passive euthanasia. Active euthanasia is taking a direct action to kill someone, to carry out a “mercy killing.” A doctor who gives a patient a lethal injection is performing active euthanasia, and so is a man who suffocates his dying brother to spare him from an unbearably painful pass- ing. Passive euthanasia is allowing someone to die by not doing something— by withholding

are intertwined with the moral concerns. Our task here is to apply moral reasoning to try to unravel the knot.


Euthanasia is directly or indirectly bringing about the death of another person for that person’s sake.2 It is thought to provide a benefit or a good for the person by ending a life deemed no longer worth living— a situation that typically arises when some- one has an incurable or terminal disease that causes great suffering or when someone experiences an irreversible loss of consciousness (as in the Schiavo case). This notion of dying as a kind of blessing is

’The Death of Karen Ann Quinlan Like nothing else before it, the case of Karen Ann Quinlan focused the world’s attention on the medical truths, the legal complexities, and the moral problems of euthanasia. She was just twenty- one years old when she sustained acute brain damage after imbibing alcohol along with a tranquilizer. She was left in a persistent vege- tative state, kept alive by a feeding tube and a respirator, a machine that maintained her breath- ing mechanically. After several months, members of her family came to accept that her recovery was hopeless and sought permission from the courts to unplug the respirator to allow her to die. Finally in 1976 the New Jersey Supreme Court granted their request. But to everyone’s surprise, she continued to breathe without the respirator until 1985, ten years after she slipped into the vegetative state. She died on June 11.*

*See “Famous Cases: Karen Ann Quinlan,” CBC News Online, March 22, 2005, http://www.cbc.ca/news2 /back ground/schiavo/vegetative_state.html (January 20, 2015); Barran H. Lerner, “Planning for the Long Goodbye,” New York Times, June 18, 2004.




the agent who ultimately causes the death in active voluntary euthanasia is the physician, whereas the ultimate causal agent in physician- assisted suicide is the patient. In the former, the physician is primarily responsible for the killing; in the latter, the patient is. In most cases, the physician provides help by pre- scribing a lethal dose of drugs, which the patient then administers to himself.

In the United States, physician- assisted suicide is legal in six states— Oregon, Washington, Montana, Colorado, Vermont, and California— and in the District of Columbia. U.S. Supreme Court rul- ings allow each state to decide for itself whether to legalize assisted suicide. The official position of the American Medical Association (AMA), the main professional group for American physicians, is that “ physician- assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.”3

A factor that can complicate all the foregoing issues is the concept of death itself. One prob- lem is that thanks to modern medical technol- ogy, determining when a person is dead is not so straightforward as it once seemed. Death has become more difficult to define. Years ago the pre- vailing notion was that a person is dead when his breathing and blood flow stop (no respiration and no heartbeat). But nowadays machines can keep an individual’s heart and lungs functioning long after the brain permanently and completely shuts down. Thus we can have an individual whose organs are mechanically operated while he is in a coma or persistent vegetative state— for years. By the traditional definition of death, such an individual would still be alive, but many people would insist that he is no longer there: he is dead. So the conventional notion of death seems to be inadequate.

Why does correctly defining death matter at all? Say an individual is in the kind of state just described. If we judge him to be dead and thus no longer a person, then perhaps it would be morally

or withdrawing measures necessary for sustaining life. A doctor, then, would be performing passive euthanasia if she removed a patient’s respirator, did not administer antibiotics to halt a life- threatening infection, or withdrew hydration and nutrition (fluids and nutrients).

Many believe that this active- passive distinc- tion is essential to understanding the moral permis- sibility of euthanasia. It allows them to maintain that whereas active euthanasia is always wrong, in some cases passive euthanasia may be permissible. This view is widespread among physicians and fits with the popular notion that killing people is mor- ally worse than letting them die. Others, however, argue that there is no moral difference between killing and letting die: in both active and passive euthanasia the patient’s death is caused, and they are therefore morally equivalent.

Taking into account the categories of voluntary, nonvoluntary, active, and passive (and disregarding involuntary), we can identify four kinds of euthana- sia: (1) active voluntary (mercy killing at the patient’s request), (2) active nonvoluntary (mercy killing with- out the patient’s consent or request), (3) passive voluntary (letting the patient die at her request), and (4) passive nonvoluntary (letting the patient die without his consent or request). Generally, the law forbids active euthanasia (either voluntary or nonvoluntary), and the medical profession is offi- cially opposed to it (though the views of individual physicians vary). Passive voluntary euthanasia is legal; by law, competent patients have the right to refuse any kind of medical treatment. Passive non- voluntary euthanasia may be legal provided that someone (a family member, for example) can be des- ignated to make decisions on behalf of the patient.

Related to, but distinct from, active voluntary euthanasia is physician- assisted suicide— the killing of a person by the person’s own hand with the help of a physician. Like active voluntary eutha- nasia, physician- assisted suicide is requested by the patient, and the intended outcome is the patient’s death for the relief of pain and suffering. But




permissible to disconnect him from the machines, or administer a fatal drug overdose, or remove his feeding tube, or even harvest his organs for trans- plant into another person. Or would it? If we deem him alive and still a person, perhaps we are not jus- tified in doing any of the above. Maybe taking any one of these actions is to commit murder. Depend- ing on the concept of death accepted by the legal system, killing him or allowing him to die could have serious legal consequences.

To overcome the drawbacks of the traditional definition of death, alternative definitions have

been suggested. According to the whole- brain defi- nition of death, an individual is dead when all brain functions (including those performed in the brain stem) permanently stop. It has become the primary standard in both medicine and the law for determining death. Critics of the whole- brain standard, though, have pointed out that it is based on a faulty assumption: that the brain is the control center for all physiological functions. Yet some functions (such as respiration) are par- tially independent of brain activity. In addition, by the whole- brain standard, individuals in an

’ In the past five decades, U.S. courts have several times weighed in on the controversial issues of euthanasia and physician- assisted suicide. The fol- lowing are some of the more far- reaching rulings:

• 1976 The New Jersey Supreme Court ruled that a life- sustaining respirator could be legally dis- connected from Karen Ann Quinlan, a young woman who had lapsed into a persistent vegeta- tive state. After it was removed, she remained comatose and lived for another ten years, finally dying in June 1985.

• 1990 The U.S. Supreme Court (in Cruzan v. Direc- tor, Missouri Department of Health) ruled that a feeding tube could be removed from Nancy Cruzan, a woman in a persistent vegetative state due to an automobile accident, if “clear and convincing evidence” shows that she would have approved of the withdrawal. The ruling recog- nized the legitimacy of living wills, surrogates to act for incapacitated individuals, and a qualified “right to die.”

• 1997 The U.S. Supreme Court (in Washington v. Glucksberg) ruled that a Washington State prohibition of physician- assisted suicide did not violate the due process clause of the Fourteenth Amendment.

• 1997 The U.S. Supreme Court (in Vacco v. Quill) ruled that a New York State prohibition of physi- cian- assisted suicide did not violate th

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