Learning Objectives:
Understanding the following

• The definitions of death, whole brain death, persistent vegetative state, and coma
• The distinction between active and passive euthanasia
• The definition of physician-assisted suicide
• The distinction between voluntary and involuntary euthanasia
• The distinction between ordinary and extraordinary measures.
•  The distinction between killing and allowing to die per the AMA
• * Familiarity for arguments    for and against euthanasia
• * Familiarity with Patient Self-Determination Act of 1990
• * Aristotle's view on euthanasia
• *Familiarity with 2 readings in text (pro and con euthanasia)

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What is euthanasia?
Euthanasia  comes from the Greek root for "Good Death."
Merriam Webster defines the term as follows: the act or practice of killing or permitting the death of hopelessly sick or injured individuals in a relatively painless way for reasons of mercy

What are the two main categories of euthanasia?
Active euthanasia & passive euthanasia.

What is passive euthanasia?
Passive euthanasia is withdrawing , withholding, or not starting  treatment , so that the patient is allowed to die a natural death.  It is the natural condition that causes the death.

What is active euthanasia?
Active euthanasia is causing the death of a patient; this is usually done via drugs.
It is also knows as mercy killing.

What is the difference between voluntary , involuntary euthanasia & non voluntary  euthanasia?
(Correction))

Voluntary euthanasia:  A mentally competent person  knowingly and freely requests euthanasia for himself.

Nonvoluntary euthanasia:  the decision is made by someone other than the patient, as the patient may be in a coma or mentally incapacitated.
If a patient has not made a living will  and is in a car accident, for example,  the decision may be made by others because the patient is incapable of speaking for himself. The parent of the child, the spouse, or the legal guardian may make the decision.  In the Nancy Cruzan case, her friends told the court what Nancy's wishes were.   Nonvoluntary does not necessarily mean unwilling.

Involuntary euthanasia:  This is a special case where the decision performing euthanasia against the patient's wishes.

 What are the two main differences between passive and active euthanasia?
1.    Death:  Passive euthanasia is passively allowing an individual to die, whereas active euthanasia is actively causing death.
2.    Legality:  While passive euthanasia is generally legally permissible when the patient is near death or when treatment would be considered an extraordinary burden for the sick individual, active euthanasia is generally legally prohibited.

What is death? (page 220-221Thiroux)          
The traditional time-honored definition is the cessation of life; a total stoppage of the circulation of blood and a cessation of the animal and vital functions, such as respiration, pulsation,.

According to the Harvard Ad Hoc  Committee, a person is dead when a person has lost all detectable brain function, including the brain stem. This is called whole brain death.   Death occurs  if and only if there is a total cessation of respiration and blood flow.  Keep in mind that lack of circulation for more than five to ten minutes causes brain death.

What is persistent vegetative state (PVS)?
This is a condition wherein the individual has no cerebral cortex function, but has some brain stem function.  Therefore, the individual retains some nonconscious functions, such as breathing, respiration, muscle control, swallowing ability... .However, the individual has lost all conscious function. One cause of PVS is that the cerebral cortex requires more blood than the brain stem, and if blood flow is discontinued for ten minutes, the cerebral cortex may "die" while the brain stem continues to function on lesser quantities of blood.
McKinnon (Ethics, Chapter 8 Euthanasia, page 138) claims a PVS "individual does not feel pain."
 
What is a coma?
A coma occurs when an individual is unconscious. "His or her brain stem functions poorly and thus this person does not live as long as someone in a persistent vegetative state" (MacKinnon, Ethics; Chapter 8 euthanasia, page 134).

Why is it important to know if a person is dead, in a PVS state, or in a coma?
Knowing that a person is dead allows a doctor to discontinue treatment.
Some ethicists  object to this term as it gives a linguistic predisposition to treat "persons" as 'vegetables.'  Persistent Vegetative State - 

According to The Harvard Ad hoc Committee (1968) Patients who are deemed brain dead, based on the Harvard Criteria,  legally dead, thus no further medical treatment is required.

 People who are in a coma or PVS are on a legal and ethical tightrope. Case studies will be discussed below.

What does it mean to take ordinary measures or extraordinary measures to preserve one's life?
Ordinary measures is ordinary care. This usually is not overly burdensome and is likely to bring good results. The benefits outweigh the burdens.
Extraordinary measures, sometimes called heroic measures, means taking actions are burdensome and may not bring good health to the patient. /the burdens outweigh the benefits.
What is extraordinary care to one person may be ordinary care for another.
A 90-year old man dying of pneumonia may now want a heart transplant if it is discovered he has heart problems too., nor would he want to undergo nauseating chemotherapy if it is discovered he has cancer.
A young individual would want to be treated more aggressively.

How does Paul Ramsey define "Ordinary Treatment"? 
All medicines, treatments, and surgical procedures that offer a reasonable hope of benefit to the patient but do not involve excessive pain, expense, or other inconveniences.

How does Ramsey define extraordinary treatment?
Measures that are unusual, extremely difficult, dangerous, inordinately expensive, or that offer no reasonable hope of benefit to the patient.

Most moralists (both religious and secular) argue that health professionals should provide ordinary treatment for the moribund, but not extraordinary.

What is physician assisted suicide?
In physician assisted suicide, a physician provides the patient with medication to commit suicide. The physician, himself,  does not inject the patient. The doctor is not the direct cause of the death.

What is the difference between killing and allowing to die per the AMA?
Killing is an act of commission.

Allowing to die presumably is an act of omission, whereby the steps needed to preserve someone's life simply are not taken. (failing to give an antibiotic shot to a terminally ill patient who has pneumonia)  When the patient dies because of nontreatment, the proximate cause of death is the patient's disease, not the name of the person who did not provide treatment.
The American Medical Association says the distinction is reasonable.

What are the Pro-Con Arguments in allowing someone to die?

Arguments against allowing someone to die

• Abandonment of patients
  • Some say refusing curative treatments makes families suffer
• The impossibility of opting for death
  • Doctors should never choose death
  • We should note that there is a difference between choosing and accepting death
• Interference with God's plan
  • Humans are not allowed to let people die or take away life.
    We must do all in our power to save life.
    Counterpoint: God did not intend that humans live forever.
• Violation of the nature and dignity of humans
• Possibility of misdiagnosis
  • Not only may one be misdiagnosed, but often one needs to have the will to live and fight for life in order to be cured and feel well again
• Possibility of finding cures
  • If you prolong a life long enough, a new miracle cure may be discovered
• Slippery Slope
  • If euthanasia becomes common, many may come to think of themselves as an emotional and financial burden to their families and feel pressured into euthanasia

Arguments for allowing someone to die:

• Individual right over one's body & life (autonomy)
  "A Patient's Bill of Rights" : We have "the right to refuse treatment to the extent permitted by law and to be informed of the medical consequences"
• Shortening period of suffering
  Thiroux's example: If a cancer patient with 8 hours of life left goes into kidney failure, starting dialysis would be an extension of pain.  Let the patient die of uremic poisoning.
• Death with Dignity rather than wasting life suffering

Patient Self-Determination Act (PSDA)  of 1990

Basically the Patient Self-Determination Act requires health care providers to inform patients of their rights and to make advance directives.

"A health care advance directive is the primary legal tool for any health care decision made when you cannot speak for yourself. "Health care advance directive" is the general term for any written statement you make while competent concerning your future health care wishes. Formal advance directives include the living will and the health care power of attorney" (American Bar Association).

What are patient rights?

• The right to considerate and respectful care
• The right to make decisions regarding their health care (in collaboration with their physician)
  • One can refuse treatment - to the extent permitted by law
  • One can appoint a surrogate
  • One can formulate advance directives
• The right to acquire information necessary to make appropriate decisions

What brought PSDA to the fore?

1990: U.S. Supreme Court Cruzan v. Missouri Health Services (227)
Recognized the right of a competent patient to refuse life-preserving medical treatment including artificial (non-oral) delivery of nutrition and water. Decision may be made by a surrogate who knows the patient's wishes  when patient is non-competent

Before this case the question of informed consent was not a major issue, because the decision of whether a patient lives or dies was answered by the parents of the incompetent patient. The Cruzan case brought with it the uncertainties of whether or not a parent or friend is choosing what the patient would want, or the parent themselves would want.

What would Aristotle have to say about euthanasia?
"Aristotle believed that willful euthanasia was wrong. Virtue, he argued, requires that we face death bravely rather than take the cowardly way out by quitting life in the face of pain and suffering. The Pythagoreans, who wrote the Hippocratic oath, also opposed euthanasia on the grounds that the gods are our keepers and we are the possessions of the gods. To kill ourselves is to sin against our gods" 'Never will I give a deadly drug, not even if I am asked for one, nor will I give any advice tending in that direction.' Hippocratic oath."  Boss Analyzing Moral Issues, Chapter 5 Euthanasia and Assisted Suicide, page 201, 2 end edition.

END OF LECTURE NOVEMBER 2006