Ethics Notes

EUTHANASIA
Active: roughly, involves killing a patient
- this is often what people have in mind when they simply speak of euthanasia
- must distinguish between active killing (may not have intent) and murdering (always has intent)
Passive: roughly, involves letting a patient die
- "Do not resuscitate." (who has signed a DNR order)
- not providing necessary treatment
     1) Withholding of Treatment
     2) Cessation of Treatment
Voluntary vs Non-Voluntary: killing or letting die in a competent person who has expressed a desire for this (usually over a sustained period of time) VS killing or letting die when the patient is unable to express such a desire (may be in a coma or past mental abilities)
NOTE: There is a difference between involuntary and non-voluntary is that involuntary actually means that the patient in question has expressed that they do not want to be euthanized while with non-voluntary you just don't know - Involuntary euthanasia is not actually considered an option in medicine


ASSISTED SUICIDE
- Not actually euthanasia since the patient ultimately kills him or herself
- the line between the two can become very thin (eg Dr. Jack Kevorkian's "Mercitron")
The Law in Canada: says the following about euthanasia
1) voluntary passive euthanasia is legal (in fact, it is required - you have the right to refuse treatment and the doctor must respect that wish if you are mentally competent)
2) voluntary active euthanasia is illegal (although reference 'The Doctrine of Double Effect' down below)
3) non-voluntary passive euthanasia is legal (under appropriate proxy decision, and legally required)
4) non-voluntary active euthanasia is illegal (again see 'The Doctrine of Double Effect')
5) assisted suicide is illegal (see the Sue Rodriguez case) but if you attempt suicide and fail it is not illegal - but no one is allowed to counsel or aid someone on taking their own life, this will result in jail time for the one who assists
- see 'Section 14 of the Criminal Code' - even if they give consent (begging even), you cannot kill them
Continuum of Incapacity:
- Coma: brain activity but not conciousness or wakefulness
- Persistent Vegetative State (PVS): wakefulness, but no awareness
- Minimally Concious State (MCS): wakefulness and minimal awareness
- Locked-in Syndrome: full conciousness and awareness, but extreme paralysis
Doctrine of Double Effect: supposed an action (eg giving a terminally ill cancer patient morphine) has some reasonably foreseeable outcome (eg overdose or quickening the patient's death) and that it would be unacceptable to perform this action for the purpose of bringing this outcome about - this comes from Christianity from the story of where God tells Abraham to sacrifice his only son. - You intend to do good ( eg manage pain with opiates) but ends up doing bad (ultimately killing the patient). - The DDE claims that it may be still acceptable to perform this action, provided that the action is not performed for the purpose of bringing this outcome about. The DDE is commonly, if not explicitly, used in medical practise


THE FUNDAMENTAL ISSUE
Premise 1) The competent patient has autonomy over his or her body, and authority over treatment choice.
- after you turn 18, and remain competent. you control what goes on with your body so long as you don't use that body to violate the rights of others
- eg. arrest, smoking, abortion
- Daniel Callaghan (1994) feels that the collective harm will be real and sufficient - people's perception of medicine as the promotion and preservation of human health will be compromised and that will effect people who should go to the hospital. (It will affect the trust people have with doctors and with medicine because they will be concerned that there will be pressure put on to euthanize the patients because it would be 'merciful', coercion?)
Premise 2) Doctors currently stop treatment in terminal cases under orders from patients or proxies.
- physicians have to respect the autonomy of patients who make this decision
Premise 3) Killing is morally equivalent to letting someone die
- this is a hot issue in philosophical circles (eg Dr James Rachels - he is a consequentialist and so he believes that morality is about outcomes, 'Death is death no matter who it came to be')
In the case of a dying patient: if the intent of removing treatment is to relieve suffering, why not adopt the quickest method (assisted suicide) rather than a slower one (withholding treatment)? But the thing is that you could say everyone is going to die, we know that, and this could lead to anyone reasoning for killing someone because it could technically prevent future unknown suffering.
- Callaghan on the other hand feels that this is totally wrong, the question for him is causation, we can work with the timing of death but we know it will happen, a physician is allowed to adjust the timing, but not the cause of it (DDE applies here)
- R v. Kitchings and Adams: victim was bounced (thrown out, left out there, landed on his face) from a bar in Manitoba, he was taken to the hospital revived but had no brain stem function, he was kept alive until kidneys were donated. The bouncers were charged but the defence claimed that the physicians killed the victim because they revived him and thus caused his death.
- see the Terri Schiavo case: P1) treatment withdrawal was approved by proxy, P2) nutrition and hydration is a form of treatment, P3) treatment withdrawal included hydration/nutrition intubations, C1) it was appropriate to remove nutrition and hydration from Schiavo - is food and water a form of treatment?
Premise 4) Killing in terminal cases would be more merciful than letting them die
- intuitively this has some appeal
- but mercy is a loaded term, mercy suggests what you do is good 'under the circumstances' ("I'm making the best of a very bad situation.") - is this making it easier for the patient, or for the proxy? who is the 'mercy' benefiting? 
Most famous case of assisted suicide in Canada is Sue Rodriguez: she had amyotrophic lateral sclerosis (ALS), her logic that when her disease has progressed significantly she wants to end her life, and Canadians are legally allowed to end their life, but by the time that she wants to end her life she will be too disabled to do it herself - she is going to need to be assisted. She argued that she was being discriminated against because of her disability and her rights were being denied. (Charter, Section 7. Right to life, liberty and dignity. - Death is a part of life.) The minority agreed that this was unfair discrimination but the majority ruled that she was being discriminated against but it was just, and based on grounds that were appropriate in the name of protecting the vulnerable against devaluation. (Define precedence here)
- Devaluating the disabled? the question becomes why are you still here? people would feel themselves or others are being selfish by not killing themselves because the resources being used on that terminally ill person could be used on someone who could get better. 
- but mercy isn't justified if I'm making a situation worse