Killing, letting die and moral perception

There are a number of arguments that purport to show, in general terms, that there is no difference between killing and letting die. These are used to justify active euthanasia on the basis of the reasons given for allowing patients to die. I argue that the general and abstract arguments fail to take account of the complex and particular situations which are found in the care of those with terminal illness. When in such situations, there are perceptions and intuitions available that do not easily find propositional form but lead most of those whose practice is in the care of the dying to resist active euthanasia. I make a plea for their intuitions to be heeded above the sterile voice of abstract premises and arguments by examining the completeness of the outline form of the pro-euthanasia argument. In doing so, I make use of Nussbaum's discussion of moral perception and general claims to be found in the literature of moral particularism.     

ONTOLOGY OR PHENOMENOLOGY? HOW THE LVAD CHALLENGES THE EUTHANASIA DEBATE

This article deals with the euthanasia debate in light of new life‐sustaining technologies such as the left ventricular assist device (LVAD). The question arises: does the switching off of a LVAD by a doctor upon the request of a patient amount to active or passive euthanasia, i.e. to ‘killing’ or to ‘letting die’? The answer hinges on whether the device is to be regarded as a proper part of the patient's body or as something external. We usually regard the switching off of an internal device as killing, whereas the deactivation of an external device is seen as ‘letting die’. The case is notoriously difficult to decide for hybrid devices such as LVADs, which are partly inside and partly outside the patient's body. Additionally, on a methodological level, I will argue that the ‘ontological’ arguments from analogy given for both sides are problematic. Given the impasse facing the ontological arguments, complementary phenomenological arguments deserve closer inspection. In particular, we should consider whether phenomenologically the LVAD is perceived as a body part or as an external device. I will support the thesis that the deactivation of a LVAD is to be regarded as passive euthanasia if the device is not perceived by the patient as a part of the body proper.     

Active and Passive Physician‐Assisted Dying and the Terminal Disease Requirement

The view that voluntary active euthanasia and physician‐assisted suicide should be made available for terminal patients only is typically warranted by reference to the risks that the procedures are seen to involve. Though they would appear to involve similar risks, the commonly endorsed end‐of‐life practices referred to as passive euthanasia are available also for non‐terminal patients. In this article, I assess whether there is good reason to believe that the risks in question would be bigger in the case of voluntary active euthanasia and physician‐assisted suicide than in that of passive euthanasia. I propose that there is not. On that basis, I suggest that limiting access to voluntary active euthanasia and physician‐assisted suicide to terminal patients only is not consistent with accepting the existing practices of passive euthanasia.     

End-of-Life Decisions and Moral Psychology: Killing, Letting Die, Intention and Foresight

In contemplating any life and death moral dilemma, one is often struck by the possible importance of two distinctions; the distinction between killing and “letting die”, and the distinction between an intentional killing and an action aimed at some other outcome that causes death as a foreseen but unintended “side-effect”. Many feel intuitively that these distinctions are morally significant, but attempts to explain why this might be so have been unconvincing. In this paper, I explore the problem from an explicitly consequentialist point of view. I first review and endorse the arguments that the distinctions cannot be drawn with perfect clarity, and that they do not have the kind of fundamental significance required to defend an absolute prohibition on killing. I go on to argue that the distinctions are nonetheless important. A complete consequentialist account of morality must include a consideration of our need and ability to construct and follow rules; our instincts about these rules; and the consequences (to the agent and to others) that might follow if the agent breaks a good general rule, particularly if this involves acting contrary to moral instinct. With this perspective, I suggest that the distinctions between killing and letting die and between intending and foreseeing do have moral relevance, especially for those involved in the care of the sick and dying.     

New developments in India concerning the policy of passive euthanasia

Euthanasia and assisted dying are illegal in India according to Sections 306 and 309 of the Indian Penal Code (IPC), and Article 21 of the Constitution of India. There have been a number of cases where the Indian High Courts and Indian Supreme Court issued differing verdicts concerning the right to life and the right to die. Nevertheless, on 7 March 2011, a paradigm shift happened as a result of the Indian Supreme Court's judgment on involuntary passive euthanasia in the case of Aruna Shanbaug. In its judgment, the Supreme Court requested the government to prepare a law on euthanasia. Accordingly, the 241st Report of the Law Commission of India proposed a bill to permit passive euthanasia. In May 2016 the Ministry of Health and Family Welfare (MOHFW) issued the draft bill for public comment in order to create an informed decision. The Indian people are divided on the issue of euthanasia. The majority of the scientific community welcome it, while some religious groups oppose it. Hindus, in general, express both supporting and opposing views on euthanasia, whereas, Christians and Muslims have hardened their opposition against it. The Supreme Court judgment and the Report of the Law Commission pave the way for the development of new policies pertaining to passive euthanasia by the central government of India. Once such legislation is passed, passive euthanasia may, and probably will, have an enormous impact on the cultural, political, public and medical spheres of India in the near future.     

Voluntary euthanasia: a utilitarian perspective

Belgium legalised voluntary euthanasia in 2002, thus ending the long isolation of the Netherlands as the only country in which doctors could openly give lethal injections to patients who have requested help in dying. Meanwhile in Oregon, in the United States, doctors may prescribe drugs for terminally ill patients, who can use them to end their life--if they are able to swallow and digest them. But despite President Bush's oft-repeated statements that his philosophy is to 'trust individuals to make the right decisions' and his opposition to 'distant bureaucracies', his administration is doing its best to prevent Oregonians acting in accordance with a law that its voters have twice ratified. The situation regarding voluntary euthanasia around the world is therefore very much in flux. This essay reviews ethical arguments regarding voluntary euthanasia and physician-assisted suicide from a utilitarian perspective. I shall begin by asking why it is normally wrong to kill an innocent person, and whether these reasons apply to aiding a person who, when rational and competent, asks to be killed or given the means to commit suicide. Then I shall consider more specific utilitarian arguments for and against permitting voluntary euthanasia.     

On the Moral Acceptability of Physician‐Assisted Dying for Non‐Autonomous Psychiatric Patients

Several authors have recently suggested that the suffering caused by mental illness could provide moral grounds for physician‐assisted dying. Yet they typically require that psychiatric‐assisted dying could come to question in the cases of autonomous, or rational, psychiatric patients only. Given that also non‐autonomous psychiatric patients can sometimes suffer unbearably, this limitation appears questionable. In this article, I maintain that restricting psychiatric‐assisted dying to autonomous, or rational, psychiatric patients would not be compatible with endorsing certain end‐of‐life practices commonly accepted in current medical ethics and law, practices often referred to as ‘passive euthanasia’.     

Reflections on the state of current debate over physician-assisted suicide and euthanasia

This paper is part of a larger project. My overall aim is to argue that the evolution of familiar forms of termination of life sustaining treatment, constituting so called passive euthanasia, has severely undercut the logic of every form of reasoning that has traditionally been used to oppose active euthanasia and assistance in suicide. Basically, there are two such forms of traditional opposition, each represented in a range of different versions. There is the inevitable argument concerning social utilities -- that permitting euthanasia and assisted suicide will have bad social consequences. But more fundamentally, the idea persists that killing is intrinsically worse than letting-die in some sense that justifies the current practice of prohibiting the first while allowing the latter. In this paper, I first consider this latter claim. My ultimate strategy, as I have said, is to show that the nature of certain things we have all come to approve regarding termination of treatment makes it next to impossible to convincingly explain, in either of these ways, what is wrong with certain forms of assistance in suicide and euthanasia. In the second part of this paper I take another step in this direction by discussing, in a preliminary way, a special case of the argument from social risks.     

REFELCTIONS ON THE STATE OF CURRENT DEBATE OVER PHYSICIAN-ASSISTED SUICIDE AND EUTHANASIA

This paper is part of a larger project. My overall aim is to argue that the evolution of familiar forms of termination of life sustaining treatment, constituting so called passive euthanasia,¹ has severaly undercut the logic of every form of reasoning that has traditionally been used to oppose active euthanasia and assistance in suicide. Basically, there are two such forms of traditional opposition, each represented in a range of different versions. There is the inevitable argument concerning social utilities — that permitting euthanasia and assisted suicide will have bad social consequences. But more fundamentally, the idea persists that killing is intrinsically worse than letting-die in some sense that justifies the current practice of prohibiting the first while allowing the latter. In this paper, I first consider this latter claim. My ultimate strategy, as I have said, is to show that the nature of certain things we have all come to approve regarding termination of treatment makes it next to impossible to convincingly explain, in either of these ways, what is wrong with certain forms of assistance in suicide and euthanasia. In the second part of this paper I take another step in this direction by discussing, in a preliminary way, a special case of the argument from social risks.     

MORAL FICTION OR MORAL FACT? THE DISTINCTION BETWEEN DOING AND ALLOWING IN MEDICAL ETHICS

Opponents of physician‐assisted suicide (PAS) maintain that physician withdrawal‐of‐life‐sustaining‐treatment cannot be morally equated to voluntary active euthanasia. PAS opponents generally distinguish these two kinds of act by positing a possible moral distinction between killing and allowing‐to‐die, ceteris paribus. While that distinction continues to be widely accepted in the public discourse, it has been more controversial among philosophers. Some ethicist PAS advocates are so certain that the distinction is invalid that they describe PAS opponents who hold to the distinction as in the grip of ‘moral fictions’. The author contends that such a diagnosis is too hasty. The possibility of a moral distinction between active euthanasia and allowing‐to‐die has not been closed off by the argumentative strategies employed by these PAS advocates, including the contrasting cases strategy and the assimilation of doing and allowing to a common sense notion of causation. The philosophical debate over the doing/allowing distinction remains inconclusive, but physicians and others who rely upon that distinction in thinking about the ethics of end‐of‐life care need not give up on it in response to these arguments.     

Neuronal Correlates of a Virtual-Reality-Based Passive Sensory P300 Network

P300, a positive event-related potential (ERP) evoked at around 300 ms after stimulus, can be elicited using an active or passive oddball paradigm. Active P300 requires a person’s intentional response, whereas passive P300 does not require an intentional response. Passive P300 has been used in incommunicative patients for consciousness detection and brain computer interface. Active and passive P300 differ in amplitude, but not in latency or scalp distribution. However, no study has addressed the mechanism underlying the production of passive P300. In particular, it remains unclear whether the passive P300 shares an identical active P300 generating network architecture when no response is required. This study aims to explore the hierarchical network of passive sensory P300 production using dynamic causal modelling (DCM) for ERP and a novel virtual reality (VR)-based passive oddball paradigm. Moreover, we investigated the causal relationship of this passive P300 network and the changes in connection strength to address the possible functional roles. A classical ERP analysis was performed to verify that the proposed VR-based game can reliably elicit passive P300. The DCM results suggested that the passive and active P300 share the same parietal-frontal neural network for attentional control and, underlying the passive network, the feed-forward modulation is stronger than the feed-back one. The functional role of this forward modulation may indicate the delivery of sensory information, automatic detection of differences, and stimulus-driven attentional processes involved in performing this passive task. To our best knowledge, this is the first study to address the passive P300 network. The results of this study may provide a reference for future clinical studies on addressing the network alternations under pathological states of incommunicative patients. However, caution is required when comparing patients’ analytic results with this study. For example, the task presented here is not applicable to incommunicative patients.     

儿童区分意图行为与自我控制能力关系的研究

目的:研究3至5岁儿童能否对主动行为、被动行为加以区分以及其控制能力的差异和两者是否相关。方法:设计两个任务:衡量儿童对主动与被动行为区分的意图实验与衡量儿童自我控制能力的七巧板任务。结果:意图实验年龄效应显著,F=48.317,P<0.001。七巧板任务年龄效应显著:F=88.123,P<0.001,意图实验与七巧板任务相关显著:r=0.79 t=8.37,P<0.01。结论:儿童对主动行为和被动行为的区分转折点为4岁;儿童的自我控制能力以坚持性为指标时转折点在4岁;儿童时意图行为的区分与自我控制能力具有相关性。     

Hungarian paediatricians' attitudes regarding the treatment and non-treatment of defective newborns: a comparative study

Conclusion: The four compared surveys clearly show that paediatricians from different backgrounds encounter these moral dilemmas in their everyday practice. Hungarian paediatricians facing morally significant decisions of discontinuation of treatment in defective newborns were permissive toward passive euthanasia like their Australian and Canadian colleagues, but were almost unanimously against active euthanasia like their Polish colleagues. The results of our study revealed a strong paternalistic attitude among Hungarian doctors, unwillingness to include other professionals in a discussion of moral problems and neglect of the nurses' views in these matters. Many physicians in the Hungarian study group were not aware of the legal ramifications in such cases. These findings were similar to the results of the Polish study. It is plausible that the paternalistic attitude and ignorance of the relevant law is common in all 'former' socialist countries. The Australian, Canadian and Hungarian doctors displayed more understanding and tolerance towards passive euthanasia. Many physicians in all study groups seemed to be not familiar with the legal regulations of their own country. The paediatricians of the four studies showed the greatest difference in their attitudes towards active euthanasia, with the Australian community being more permissive, the Canadian, Polish and Hungarian community rejecting it.     

Euthanasia.

The principles of self-determination and individual well-being support the use of voluntary euthanasia by those who do not have moral or professional objections to it. Opponents of this posture cite the ethical wrongness of the act itself and the folly of any public or legal policy permitting euthanasia. Positive consequences of making euthanasia legally permissible respect the autonomy of competent patients desiring it, expand the population of patients who can choose the option, and release the dying patient from otherwise prolonged suffering and agony. Potentially bad consequences of permitting euthanasia include the undermining of the "moral center" of medicine by allowing physicians to kill, the weakening of society's commitment to provide optimal care for dying patients, and, of greatest concern, the "slippery slope" argument. The evaluation of the arguments leads to support for euthanasia, with its performance not incompatible with a physician's professional commitment.     

Positive killing and the irreversibly unconscious patient

Ethical arguments against active, involuntary euthanasia are examined and held to be unconvincing in the case of patients, who though irreversibly comatose, possess spontaneous cardiopulmonary function. It is further contended that positive killing may be the morally superior course of action for physicians in a restricted range of cases.     

Two Decades of Research on Euthanasia from the Netherlands. What Have We Learnt and What Questions Remain?

Two decades of research on euthanasia in the Netherlands have resulted into clear insights in the frequency and characteristics of euthanasia and other medical end-of-life decisions in the Netherlands. These empirical studies have contributed to the quality of the public debate, and to the regulating and public control of euthanasia and physician-assisted suicide. No slippery slope seems to have occurred. Physicians seem to adhere to the criteria for due care in the large majority of cases. Further, it has been shown that the majority of physicians think that the euthanasia Act has improved their legal certainty and contributes to the carefulness of life-terminating acts. In 2005, eighty percent of the euthanasia cases were reported to the review committees. Thus, the transparency envisaged by the Act still does not extend to all cases. Unreported cases almost all involve the use of opioids, and are not considered to be euthanasia by physicians. More education and debate is needed to disentangle in these situations which acts should be regarded as euthanasia and which should not. Medical end-of-life decision-making is a crucial part of end-of-life care. It should therefore be given continuous attention in health care policy and medical training. Systematic periodic research is crucial for enhancing our understanding of end-of-life care in modern medicine, in which the pursuit of a good quality of dying is nowadays widely recognized as an important goal, in addition to the traditional goals such as curing diseases and prolonging life.     

A simple unconstrained dynamic knee simulator

The design of a simple dynamic knee simulator is described. In the simulator the joint dynamics are reproduced in-vitro in a knee specimen by controlling the time-histories of the tensions in two flexible cables acting as lumped muscle group equivalents, without constraining the natural conjunct and passive motions of the specimen. The two cable tensions acting individually are used to control the active flexion/extension motion, while their simultaneous action is used to control joint compressive force. The characteristics of the electrohydraulic servo system acting under real-time microprocessor control are described. The system performance during simulation of an idealized level-walking function is evaluated.     

Alberta euthanasia survey: 1. Physicians' opinions about the morality and legalization of active euthanasia.

OBJECTIVE: To ascertain the opinions of a sample of Alberta physicians about the morality and legalization of active euthanasia, the determinants of these opinions and the frequency and sources of requests for assistance in active euthanasia. DESIGN: Cross-sectional survey of a random sample of Alberta physicians, grouped by site and type of practice. SETTING: Alberta. PARTICIPANTS: A total of 2002 (46%) of the licensed physicians in Alberta were mailed a 38-item questionnaire in May through July 1991; usable responses were returned by 1391 (69%). RESULTS: Of the respondents 44% did believe that it is sometimes right to practice active euthanasia; 46% did not. Moral acceptance of active euthanasia correlated with type of practice and religious affiliation and activity. In all, 28% of the physicians stated that they would practice active euthanasia if it were legalized, and 51% indicated that they would not. These opinions were significantly related to sex, religious affiliation and activity, and country of graduation. Just over half (51%) of the respondents stated that the law should be changed to permit patients to request active euthanasia. Requests (usually from patients) were reportedly received by 19% of the physicians, 78% of whom received fewer than five. CONCLUSIONS: This survey revealed severely disparate opinions among Alberta physicians about the morality of active euthanasia. In particular, religious affiliation and activity were associated with the polarized opinions. The desire for active euthanasia, as inferred from requests by patients, was not frequent. Overall, there was no strong support expressed by the physicians for the personal practice of legalized active euthanasia. These data will be vital to those involved in health education and public policy formation about active euthanasia in Alberta and the rest of Canada.     

Interactive effects of Na and K in killing by human natural killer cells

Contact-mediated lysis by human natural killer cells is inhibited by a number of drugs that block the predominant K channel. In this study we have further examined the role of the K channel and the interactions between passive K and Na transport in killing. Low external Na-inhibited killing and inhibition were not due to reduce inward current through the Na channels in the target cell. A role for the Na/H antiport is suggested since amiloride inhibited killing in a dose-dependent manner that was competitive with external Na. Depolarizing the killer cell with elevated external K did not inhibit killing. On the contrary, high K0 reduced the inhibition caused by low Na0 and by the K-channel blockers quinidine, verapamil, and retinoic acid. Hyperpolarizing the killer cell with low K0 or valinomycin inhibited killing. Valinomycin, which should prevent the depolarization caused by K-channel block, did not reverse the effect of the blockers quinidine, verapamil, and 4-aminopyridine. Hence, the primary role of the K channels during killing is not maintain the negative membrane potential. On the contrary, depolarization may promote killing under conditions where killing is submaximal.