Hastening death and respect for dignity: Kantianism at the end of life

Suppose that a young athlete has just become quadriplegic. He expects to live several more decades, but out of self‐interest he autonomously chooses to engage in physician‐assisted suicide (PAS) or voluntary active euthanasia (VAE). Some of us are unsure whether he or his physician would be acting rightly in ending his life. One basis for such doubt is the notion that persons have dignity in a Kantian sense. This paper probes responses that David Velleman and Frances Kamm have suggested to the question of whether participating in PAS or VAE to benefit oneself, as the young man might, respects the dignity of persons, specified in an orthodox Kantian way. Velleman claims that it does not, while Kamm insists that, in certain circumstances, it does. I argue against Kamm's position. I go on to contend that while orthodox Kantianism might provide a basis for moral concern regarding the case of the young quadriplegic, it suffers from two serious shortcomings. First, it implies that terminally ill patients are wrong to request VAE or engage in PAS to avoid intense suffering, at least when this suffering has not yet overwhelmed their reason. Second, orthodox Kantianism implies that it is wrong for physicians to withdraw such patients from life‐sustaining treatments, even if they request it. To remedy these shortcomings, I sketch an unorthodox Kantian account of respect for the dignity of persons. This account promises to capture the idea that it would be morally problematic for doctors to help the young quadriplegic to die, but to avoid the shortcomings of an orthodox Kantian account.     

Anticipating an unwanted future: euthanasia and dementia in the Netherlands

This ethnographic exploration of anticipation draws on fieldwork among people with dementia and their families in the Netherlands. I examine how requests for euthanasia by people with dementia offer insight into the work of anticipation, revealing it to be a temporal orientation through which the future is made tangible. Imagining a future with dementia may prompt some people to request euthanasia, but timing such measures is extremely difficult and often results in deferral. Contributing to an emerging anthropology of time, I argue that anticipation is a process of establishing, collapsing, and renegotiating the temporal distance between present and future, bringing the future into the present while also, and simultaneously, keeping the future at bay as a continuous ‘not yet’.     

The ethics of euthanasia: advocates' perspectives

The Netherlands is currently the only country in the world in which euthanasia is legally permissible. More specifically, Dutch law (briefly explained) allows that a doctor terminates the life of a patient of hers on his voluntary, well-considered and sustained request, if he is suffering unbearably and hopelessly. The aim of this paper is to reconstruct the Dutch debate on the moral permissibility of euthanasia so as to clarify and strengthen the various views that can be advanced in support of euthanasia. On the one view, The Pure Autonomy View (TPAV), the justification of euthanasia rests solely on the principle of respect for autonomy. That is, the reason for performing and permitting euthanasia is the patient's voluntary, well-considered and sustained, in one word: autonomous, request for euthanasia. On the alternative view, The Joint View (TJV), the principle of respect for autonomy and the principle of beneficence morally justify euthanasia together . That is, euthanasia is ethical if and partly because, since the patient is suffering unbearably and hopelessly, euthanasia is in his interest. According to this paper, there is no easy argument for one of these views rather than the other. Instead, as yet both TPAV and TJV seem inherently problematic. TPAV is unable to give a doctor a reason for performing euthanasia that appeals to her in her capacity as a doctor, such as relief of suffering. And TJV begs the question – for example, if a state were to legalize euthanasia on grounds of TJV, it would force the view upon its citizens that it may be in a person's interest to die.     

Execution by lethal injection, euthanasia, organ-donation and the proper goals of medicine

In a recent issue of this journal, David Silver and Gerald Dworkin discuss the physicians' role in execution by lethal injection. Dworkin concludes that discussion by stating that, at that point, he is unable to think of an acceptable set of moral principles to support the view that it is illegitimate for physicians to participate in execution by lethal injection that would not rule out certain other plausible moral judgements, namely that euthanasia is under certain conditions legitimate and that organ-donation surgery is sometimes permissible. This article draws attention to some problems in the views of Silver and Dworkin and suggests moral principles which support the three moral views just mentioned.     

A Kantian ethics approach to moral bioenhancement

It seems, at first glance, that a Kantian ethics approach to moral enhancement would tend towards the position that there could be no place for emotional modulation in any understanding of the endeavour, owing to the typically understood view that Kantian ethics does not allow any role for emotion in morality as a whole. It seems then that any account of moral bioenhancement which places emotion at its centre would therefore be rejected. This article argues, however, that this assumption is incorrect. Given later writings by Kant on the role of sympathy, and taking into account other concerns in Kantian ethics (such as bodily integrity), it may in fact be the case that Kantian ethics would allow for an account of moral bioenhancement through emotional modulation, and that in some (rare) cases such an intervention might even be considered to be a duty.     

‘Alive by default’: An exploration of Velleman’s unfair burdens argument against state sanctioned euthanasia

In this article we critically evaluate an argument against state-sanctioned euthanasia made by David Velleman in his 1992 paper ‘Against the right to die’. In that article, Velleman argues that legalizing euthanasia is morally problematic as it will deprive eligible patients of the opportunity of staying ‘alive by default’. That is to say, those patients who are rendered eligible for euthanasia as a result of legislative reform will face the burden of having to justify their continued existence to their epistemic peers if they are to be perceived as ‘reasonable’. We discuss potential criticisms that could be made of the argument, and consider how a defender of the view might respond. Velleman’s argument is particularly interesting as it is a consequentialist argument against state-sanctioned euthanasia, challenging the many consequentialist arguments that have been made in favour of legalizing the procedure. We conclude by suggesting that further research on the question of unfair burdens is important to adequately evaluating the potential harms of legalizing euthanasia for patients at the end of life.     

Bioethics and political ideology: the case of active voluntary euthanasia

In different countries responses to important bioethical issues are different, as exemplified by the attitudes towards the voluntary and active forms of medical euthanasia. But why is this the case? My suggestion is that the roots of the variety are, to be considerable degree, ideological. The most important present-day political ideologies all have their roots in the prevailing doctrines of moral and social philosophy. In the paper these doctrines are outlined and the predicted response towards active voluntary euthanasia within each model is sketched. The conclusion reached is that while it would in some countries be dangerous to allow euthanasia in the prevailing circumstances, the solution is not to hinder the legalization process but to alter the circumstances.     

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.     

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.     

Illness, suffering and voluntary euthanasia

It is often accepted that we may legitimately speak about voluntary euthanasia only in cases of persons who are suffering because they are incurably injured or have an incurable disease. This article argues that when we consider the moral acceptability of voluntary euthanasia, we have no good reason to concentrate only on persons who are ill or injured and suffering.     

Aversion to gaseous euthanasia agents in rats and mice

Despite euthanasia being the most common of all procedures carried out on laboratory animals, the potential distress associated with gaseous agents has received little interest until recently, with growing concern over use of carbon dioxide as a humane method of euthanasia. The distress associated with exposure to carbon dioxide, argon, and carbon dioxide-argon mixtures was investigated in rats and mice by measuring the degree of aversion on exposure to low, medium, and high concentrations of these agents. Animals were exposed to the various concentrations in a test chamber containing air or gas mixtures that they were able to enter and leave at will. Aversion was assessed, using measurements of initial withdrawal time and total dwelling time in the test chamber, as they were the most sensitive measurements of aversion. Comparisons between euthanasia agent and control (air) treatments indicated that concentrations of agents recommended for rapid and efficient induction are associated with some degree of aversion. Carbon dioxide and the carbon dioxide-argon mixtures were more aversive than was argon for rats and mice. These findings suggest that induction with carbon dioxide either alone or in combination with argon is likely to cause considerable distress before the loss of consciousness in rodents, which is unacceptable considering that effective and more humane alternatives are available.     

The evolution of euthanasia and its perceptions in Greek culture and civilization

Death has preoccupied humanity since before the dawn of civilization. As a multidimensional and moral problem, the end of life has concerned different civilizations, and different approaches to euthanasia, or "good death," have been developed in each culture. In Greece, there is a long record of the culture's evolving attitudes toward death and euthanasia.A more widespread knowledge of the views and traditions surrounding the act of euthanasia can contribute to a better understanding of the controversies surrounding modern attitudes and practice.     

A Survey of Veterinarians’ Attitudes toward Euthanasia of Companion Animals in Japan

This study investigated veterinarians’ attitudes toward euthanasia of companion animals in Japan. A nationwide survey was conducted with 932 veterinarians in small animal practices. It examined the number of times they administered euthanasia, their moral criteria for choosing euthanasia for animals, and their behavioral criteria for suggesting euthanasia to owners. According to the data analyses, on average the veterinarians administered euthanasia 2.48 times a year. For many veterinarians, two conditions were necessary to justify euthanasia for animals: “the animals are incurable and suffering” and “the owners request to euthanize the animals.” In the absence of either condition, the veterinarians were inclined to disapprove of choosing euthanasia. If the owners requested further treatment, 67% showed clear disapproval of choosing euthanasia for animals with serious medical conditions. Meanwhile, more than 76% showed clear disapproval of euthanizing healthy animals when the owners requested it. These results indicate that the owners’ request takes precedence over the animals’ condition for suffering animals, but not for healthy animals. For animals with serious medical conditions, 56% of the veterinarians answered that they would or might suggest euthanasia to the owners even though the owners requested further treatment. In this situation, for some veterinarians, the animals’ condition rather than the owners’ request might become a determinant in suggesting euthanasia to owners, even if their moral judgments were against choosing euthanasia for the animals. A decrease in the owners’ or the animals’ quality of life and the owners’ inability to pay were not primary factors in choosing or suggesting euthanasia. Having an experience of euthanizing their own animals was a key factor for the veterinarians which increased not only the number of times they administered euthanasia but also the degree of their moral approval of choosing euthanasia and their behavioral willingness to suggest it to owners.     

Alberta euthanasia survey: 2. Physicians' opinions about the acceptance of active euthanasia as a medical act and the reporting of such practice.

OBJECTIVE: To ascertain the opinions of Alberta physicians about the acceptance of active euthanasia as a medical act (the "medicalization" of active euthanasia) and the reporting of colleagues practising active euthanasia, as well as the sociodemographic correlates. 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: Although only 44% of the respondents considered active euthanasia morally "right" at least 70% opted to medicalize the practice if it were legal by restricting it to be performed by physicians and to be taught at medical sites. Even though active euthanasia is criminal homicide in Canada, 33% of the physicians stated that they would not report a colleague participating in the act of anyone, and 40% and 60% stated that they would not report a colleague to medical or legal authorities respectively. Acceptance or rejection of active euthanasia as a medical act was strongly related to religious affiliation and activity (p < 0.01). CONCLUSIONS: This survey about active euthanasia revealed profound incongruities in the opinions of the sample of Alberta physicians concerning their ethical and social duties in the practice of medicine. These data highlight the need for relevant modifications of health education policies concerning biomedical ethics and physicians'' obligations to society.     

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.     

MORAL ENHANCEMENT VIA DIRECT EMOTION MODULATION: A REPLY TO JOHN HARRIS

Some argue that humans should enhance their moral capacities by adopting institutions that facilitate morally good motives and behaviour. I have defended a parallel claim: that we could permissibly use biomedical technologies to enhance our moral capacities, for example by attenuating certain counter‐moral emotions. John Harris has recently responded to my argument by raising three concerns about the direct modulation of emotions as a means to moral enhancement. He argues (1) that such means will be relatively ineffective in bringing about moral improvements, (2) that direct modulation of emotions would invariably come at an unacceptable cost to our freedom, and (3) that we might end up modulating emotions in ways that actually lead to moral decline. In this article I outline some counter‐intuitive potential implications of Harris' claims. I then respond individually to his three concerns, arguing that they license only the very weak conclusion that moral enhancement via direct emotion modulation is sometimes impermissible. However I acknowledge that his third concern might, with further argument, be developed into a more troubling objection to such enhancements.     

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.     

Managing intentions: the end-of-life administration of analgesics and sedatives, and the possibility of slow euthanasia

There has been much debate regarding the 'double-effect' of sedatives and analgesics administered at the end-of-life, and the possibility that health professionals using these drugs are performing 'slow euthanasia.' On the one hand analgesics and sedatives can do much to relieve suffering in the terminally ill. On the other hand, they can hasten death. According to a standard view, the administration of analgesics and sedatives amounts to euthanasia when the drugs are given with an intention to hasten death. In this paper we report a small qualitative study based on interviews with 8 Australian general physicians regarding their understanding of intention in the context of questions about voluntary euthanasia, assisted suicide and particularly the use of analgesic and sedative infusions (including the possibility of voluntary or non-voluntary 'slow euthanasia'). We found a striking ambiguity and uncertainty regarding intentions amongst doctors interviewed. Some were explicit in describing a 'grey' area between palliation and euthanasia, or a continuum between the two. Not one of the respondents was consistent in distinguishing between a foreseen death and an intended death. A major theme was that 'slow euthanasia' may be more psychologically acceptable to doctors than active voluntary euthanasia by bolus injection, partly because the former would usually only result in a small loss of 'time' for patients already very close to death, but also because of the desirable ambiguities surrounding causation and intention when an infusion of analgesics and sedatives is used. The empirical and philosophical implications of these findings are discussed.     

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’.     

Ethical dilemmas in early detection of dementia. An inventory of moral intuitions in practice

In this article we present an inventory of the moral intuitions of the health care workers who work in the field of early detection of dementia. The effects of pharmacological treatment and professional care and support may improve when dementia is detected in an early stage. Furthermore, the patient (and his family) can prepare themselves for the period to come. Health care workers recognize moral problems and tensions concerning early detection that are related to the question whether persons will benefit from knowledge in an earlier stage of dementia, because this knowledge can be a heavy burden. We asked general practitioners, home care workers, employees of the so-called 'Memory clinic' and specialists, what ethical intuitions they recognize in practice. They mentioned the following questions: when are health care professionals allowed to take initiative, is causing worries and concerns problematic, and should a diagnosis always to be told? We conclude after a first analysis that many moral questions derive from the fact that many health care professionals lack knowledge of the wishes and interests of the elderly. At the same time they try to justify their actions on the (presupposed) consent of the elderly person. We suggest that the general norm 'only act when the patient wants to be helped' in health care should also apply to detection of dementia, although it should not be taken too strictly. Another justification for early detection can be found in the benefits for the elderly people, when their wishes are no longer expressed.