Physician-Assisted SuicidePhysician-Assisted Suicide

PHL281Y BioethicsPHL281Y BioethicsSummer 2005 University of TorontoSummer 2005 University of Toronto

Prof. Kirstin BorgersonProf. Kirstin BorgersonCourse Website: www.chass.utoronto.ca/~kirstinCourse Website: www.chass.utoronto.ca/~kirstin

OverviewOverview

Case: DianeCase: Diane

Defining Physician-Assisted Suicide (PAS)Defining Physician-Assisted Suicide (PAS)

Drawing the line at PAS:Drawing the line at PAS: Quill, Cassel and MeierQuill, Cassel and Meier WolfWolf

Slippery Slope ArgumentsSlippery Slope Arguments

Case: Sue RodriguezCase: Sue Rodriguez

The Hippocratic OathThe Hippocratic Oath

DianeDiane

““I had come to know, respect, and admire her over the past I had come to know, respect, and admire her over the past eight years” (Quill, 692)eight years” (Quill, 692)

Independent, in controlIndependent, in control Diagnosis: acute myelomonocytic leukemiaDiagnosis: acute myelomonocytic leukemia Odds 25% survival with aggressive treatmentOdds 25% survival with aggressive treatment Refused treatmentRefused treatment Overdosed with prescription barbituratesOverdosed with prescription barbiturates Physician said she died of ‘acute leukemia’Physician said she died of ‘acute leukemia’

““I wonder why Diane, who gave so much to so many of us, I wonder why Diane, who gave so much to so many of us, had to be alone for the last hour of her life.” (694)had to be alone for the last hour of her life.” (694)

Physician-Assisted Suicide Physician-Assisted Suicide (PAS)(PAS)

““Suicide carried out with the assistance of a doctor Suicide carried out with the assistance of a doctor (whose role is typically to provide a lethal dose of a (whose role is typically to provide a lethal dose of a drug at the explicit request of the patient)” drug at the explicit request of the patient)” (OED)(OED)

Distinguished from VAE:Distinguished from VAE: The final act is solely the patient’s (causal pathway)The final act is solely the patient’s (causal pathway)

Distinguished from VPE:Distinguished from VPE: Physician provides means to death (prescription for lethal Physician provides means to death (prescription for lethal

dose)dose)

Quill, Cassel, MeierQuill, Cassel, Meier

VAE ---/--- PAS ------ VPEVAE ---/--- PAS ------ VPE

Argued: no essential difference between Argued: no essential difference between physician-assisted suicide and termination physician-assisted suicide and termination of life-sustaining treatment (passive of life-sustaining treatment (passive euthanasia)euthanasia)

AnalogyAnalogy Principles and VPEPrinciples and VPE

Why PAS but not VAE?Why PAS but not VAE?

Role of Medical ProfessionRole of Medical Profession

Risk of Abuse:Risk of Abuse: ““In assisted suicide, the final act is solely the patient’s, and the In assisted suicide, the final act is solely the patient’s, and the

risk of subtle coercion from doctors, family members, risk of subtle coercion from doctors, family members, institutions, or other social forces is greatly reduced” (421)institutions, or other social forces is greatly reduced” (421)

Power and controlPower and control In the USA right now, medical care is “too inequitable”; doctor-In the USA right now, medical care is “too inequitable”; doctor-

patient relationships are “too impersonal” (422)patient relationships are “too impersonal” (422)

But: some patients who cannot swallow or move will be But: some patients who cannot swallow or move will be unable to receive PAS unable to receive PAS

This is thought to be “less than ideal” but necessary in light This is thought to be “less than ideal” but necessary in light of risks of abuse (cost/benefit analysis) (422)of risks of abuse (cost/benefit analysis) (422)

Cost/Benefit AnalysisCost/Benefit Analysis

ObjectionObjection

Case of the borrowed gunCase of the borrowed gun

Suggested principle: Suggested principle: Providing means for others’ Providing means for others’ destruction is wrongdestruction is wrong

Implications for PAS?Implications for PAS?

ReplyReply

Modified principle: Modified principle:

‘‘Providing means for others’ destruction is wrong Providing means for others’ destruction is wrong in cases where the person is in condition x’in cases where the person is in condition x’

Where x = a condition that interferes with Where x = a condition that interferes with competencecompetence

Lesson for PAS: restrictions neededLesson for PAS: restrictions needed

PAS Criteria Proposed by PAS Criteria Proposed by Q,C,MQ,C,M

Because PAS is extraordinary and irreversible, Because PAS is extraordinary and irreversible, the following conditions must be met:the following conditions must be met:

1.1. Incurable condition with severe sufferingIncurable condition with severe suffering2.2. Adequate comfort care has been providedAdequate comfort care has been provided3.3. Clear and repeated request to die (no surrogate Clear and repeated request to die (no surrogate

requests or advance directive requests, though)requests or advance directive requests, though)4.4. Competence (not depressed, good understanding)Competence (not depressed, good understanding)5.5. Context of meaningful doctor-patient relationship Context of meaningful doctor-patient relationship

(note: right of conscientious refusal by doctor)(note: right of conscientious refusal by doctor)6.6. Second opinion (consultation)Second opinion (consultation)7.7. Clear documentation to support each conditionClear documentation to support each condition

Justifiable Restrictions?Justifiable Restrictions?

Terminally ill?Terminally ill?

Advance directives?Advance directives?

Missing elements?Missing elements?

WolfWolf

VAE ------ PAS ---/--- VPEVAE ------ PAS ---/--- VPE

Wolf agrees with concerns raised with VAEWolf agrees with concerns raised with VAE Extends these concerns to PASExtends these concerns to PAS Reminds us of the importance of social Reminds us of the importance of social

context in discussions of ethical issuescontext in discussions of ethical issues Argues: historically/socially vulnerable Argues: historically/socially vulnerable

populations (gender, race, socio-economic populations (gender, race, socio-economic status) may be differentially affected by status) may be differentially affected by legalization of PASlegalization of PAS

Predictive hypotheses (Wolf)Predictive hypotheses (Wolf) Possible differential effects of PAS (using the Possible differential effects of PAS (using the

case of women, but can be extended to other case of women, but can be extended to other vulnerable groups):vulnerable groups):

1.1. Higher incidence of women dying by PASHigher incidence of women dying by PAS

In US, women are less likely to have health insuranceIn US, women are less likely to have health insurance Women are over-represented in the ranks of the poorWomen are over-represented in the ranks of the poor Women have less access to resources (such as home Women have less access to resources (such as home

care)care) Women are less likely to receive good attention from Women are less likely to receive good attention from

physicians even when insurance is the samephysicians even when insurance is the same Women are at greater risk for inadequate pain reliefWomen are at greater risk for inadequate pain relief Women are at greater risk for depressionWomen are at greater risk for depression Women more often use attempts at suicide as calls for Women more often use attempts at suicide as calls for

help or changehelp or change

Predictive Hypotheses Predictive Hypotheses (Wolf)(Wolf)

2. Women might seek PAS for different (and less acceptable) 2. Women might seek PAS for different (and less acceptable) reasons reasons

Women are more likely to be moved by a desire not to be Women are more likely to be moved by a desire not to be burdens on the familyburdens on the family

3. Physicians’ decisions may be affected by gender 3. Physicians’ decisions may be affected by gender stereotypesstereotypes

Historical and poetic valorization of women’s self-sacrifice Historical and poetic valorization of women’s self-sacrifice (especially sacrifices by older women)(especially sacrifices by older women)

4. Many people envision women as recipients when discussing 4. Many people envision women as recipients when discussing PAS and this may (negatively) influence our reasoningPAS and this may (negatively) influence our reasoning

Gender issues may influence broad public debate on PAS and Gender issues may influence broad public debate on PAS and euthanasiaeuthanasia

Empirical Evidence?Empirical Evidence?

Wolf tries to use empirical evidence to make her caseWolf tries to use empirical evidence to make her case

We now have better evidence (from Oregon, for example)We now have better evidence (from Oregon, for example)

First predictive hypotheses isFirst predictive hypotheses is not supported – not supported – almost exactly almost exactly 50/50 men/women dying in Oregon50/50 men/women dying in Oregon

Second hypothesis isSecond hypothesis is somewhat supported somewhat supported – women choose – women choose PAS more often for reasons such as “being a burden” PAS more often for reasons such as “being a burden”

Third hypothesis is Third hypothesis is somewhat supportedsomewhat supported (though it is difficult (though it is difficult to assess) – those requesting PAS are more often younger and to assess) – those requesting PAS are more often younger and higher educated which seems to go against the stereotype of higher educated which seems to go against the stereotype of the older, poorer women who sacrifice themselves for their the older, poorer women who sacrifice themselves for their familiesfamilies

Social Context (Wolf)Social Context (Wolf)

Fourth hypothesis - our reasoning about PAS is affected by:Fourth hypothesis - our reasoning about PAS is affected by:

Women used in fictional cases (It’s Over Debbie)Women used in fictional cases (It’s Over Debbie) Message – powerful men should relieve suffering of vulnerable womenMessage – powerful men should relieve suffering of vulnerable women

Women used in actual cases (Dr. Kevorkian)Women used in actual cases (Dr. Kevorkian) First eight subjects womenFirst eight subjects women Why?Why?

Chance? Chance? Misogynist?Misogynist? Sexist society and poetic/emotional appeal of women’s suffering and death? Sexist society and poetic/emotional appeal of women’s suffering and death? ??

Evaluation of hypothesis?Evaluation of hypothesis? Society’s sexism is reflected in these cases and may be Society’s sexism is reflected in these cases and may be

influencing the debateinfluencing the debate

Lessons from WolfLessons from Wolf

Context matters (reflective equilibrium)Context matters (reflective equilibrium)

Good idea to pay attention to differential death rates – is Good idea to pay attention to differential death rates – is one group using PAS more often? Could this be a result of one group using PAS more often? Could this be a result of social pressures? social pressures?

How, in general, do we deal with social pressures in How, in general, do we deal with social pressures in medicine? What impact does this sort of general social medicine? What impact does this sort of general social pressure, coercion or manipulation have on people’s pressure, coercion or manipulation have on people’s decisions? (We will see this again in the debate over decisions? (We will see this again in the debate over reproductive technologies)reproductive technologies)

Justice in health careJustice in health care

Abuse, Safeguards and Abuse, Safeguards and LegalizationLegalization

Opponents of euthanasia frequently warn of the possible Opponents of euthanasia frequently warn of the possible negative consequences of legalizing physician assisted negative consequences of legalizing physician assisted suicide and active euthanasia (PAS/AE) while ignoring the suicide and active euthanasia (PAS/AE) while ignoring the covert practice of PAS/AE by doctors and other health covert practice of PAS/AE by doctors and other health professionals. professionals.

Studies in the USA, Netherlands, and Australia suggest that Studies in the USA, Netherlands, and Australia suggest that approximately 4% to 10% of physicians have intentionally approximately 4% to 10% of physicians have intentionally assisted a patient to die (whether PAS or AE).assisted a patient to die (whether PAS or AE).

Are we more or less likely to address issues raised by Are we more or less likely to address issues raised by vulnerable populations if PAS and AE remain illegal (vs. vulnerable populations if PAS and AE remain illegal (vs. legal with safeguards)?legal with safeguards)?

Slippery Slope Arguments Slippery Slope Arguments Structure:Structure: If a(1) then a(2), if a(2) then a(3), if a(3) then a(4)… if a(n-1) then a(n). But we If a(1) then a(2), if a(2) then a(3), if a(3) then a(4)… if a(n-1) then a(n). But we

don’t want a(n). Therefore not a(1). don’t want a(n). Therefore not a(1).

Ex/ If we allow abortion then we will have to allow infanticide; if we allow Ex/ If we allow abortion then we will have to allow infanticide; if we allow infanticide, infanticide, we will have to allow the murder of ‘undesirable’ types of people. We we will have to allow the murder of ‘undesirable’ types of people. We don’t want that so we had better not allow abortion.don’t want that so we had better not allow abortion.

Ex/ If we allow PAS in cases where the patient has given explicit informed Ex/ If we allow PAS in cases where the patient has given explicit informed consent, we will have to allow PAS for those who have left written advance consent, we will have to allow PAS for those who have left written advance directives. If we allow PAS on the basis of written advance directives, we will directives. If we allow PAS on the basis of written advance directives, we will have to allow proxy decision-makers to decide on PAS for patients who have have to allow proxy decision-makers to decide on PAS for patients who have become incompetent. We will then have to allow doctors to make decisions become incompetent. We will then have to allow doctors to make decisions about PAS for patients who have no advance directive or proxy but who ‘would about PAS for patients who have no advance directive or proxy but who ‘would have wanted’ PAS. Next, we will create some ‘objective’ test for patients have wanted’ PAS. Next, we will create some ‘objective’ test for patients (including newborns) whose best interests would be served by dying, and from (including newborns) whose best interests would be served by dying, and from there we will make decisions about which infants should receive NAE. Finally, there we will make decisions about which infants should receive NAE. Finally, we will be making decisions about which children and adults should be we will be making decisions about which children and adults should be euthanized, in spite of their expressed wishes (IAE). euthanized, in spite of their expressed wishes (IAE).

Slippery Slope ArgumentsSlippery Slope Arguments

Possible problems with these arguments? Possible problems with these arguments?

At each step, we make a prediction. If we multiply the probabilities, the At each step, we make a prediction. If we multiply the probabilities, the resulting probability of the chain is reduced. If the probability at each step resulting probability of the chain is reduced. If the probability at each step is 80%, then the likelihood of a(1) -> a(n) if there are 6 steps is only 33%. is 80%, then the likelihood of a(1) -> a(n) if there are 6 steps is only 33%. The more steps involved, the less strong the argument. The more steps involved, the less strong the argument.

Slippery slope arguments rest on fuzzy distinctions. If at any point we can Slippery slope arguments rest on fuzzy distinctions. If at any point we can make a clear distinction and ‘draw the line’ we can stop sliding down the make a clear distinction and ‘draw the line’ we can stop sliding down the slope. slope.

There is no reason to think that the first step must logically lead to the There is no reason to think that the first step must logically lead to the second step as long as we clearly define and defend the first step and fail second step as long as we clearly define and defend the first step and fail to see a similar defense for the second step. to see a similar defense for the second step.

We are often We are often psychologicallypsychologically compelled to slide down the slope but that compelled to slide down the slope but that does not mean we are does not mean we are logicallylogically compelled. compelled.

So…So…

Can we make moral distinctions Can we make moral distinctions between: between:

VPE… PAS… VAE… NAE… IAE… VPE… PAS… VAE… NAE… IAE… Genocide?Genocide?

Moral Principles in Legal Moral Principles in Legal DebatesDebates

We will now look at some of the We will now look at some of the specific concerns arising in the legal specific concerns arising in the legal debate over AE and PASdebate over AE and PAS

Allows us to pay some attention to Allows us to pay some attention to moral issues raised by individual moral issues raised by individual cases (part of reflective equilibrium)cases (part of reflective equilibrium)

Facts: Legal StatusFacts: Legal Status

Active Euthanasia: Active Euthanasia: Netherlands (legalized 2002, permitted since 1984)Netherlands (legalized 2002, permitted since 1984) Belgium (legalized 2002)Belgium (legalized 2002)

Physician-assisted Suicide:Physician-assisted Suicide: Oregon, USA (legalized 1997)Oregon, USA (legalized 1997) Switzerland (1941)Switzerland (1941)

76% of surveyed Canadians said they support the 76% of surveyed Canadians said they support the ‘right to die’ – Angus Reid Polls 1993 & 1997 ‘right to die’ – Angus Reid Polls 1993 & 1997 (steady response)(steady response)

CanadaCanada

Canada – AE and PAS illegal (though Canada – AE and PAS illegal (though sometimes not prosecuted)sometimes not prosecuted)

Criminal Code Section 241Criminal Code Section 241 Every one who Every one who

(a)(a) counsels a person to commit suicide, orcounsels a person to commit suicide, or(b)(b) aids or abets a person to commit suicide whether aids or abets a person to commit suicide whether

suicide ensues or not,suicide ensues or not,

is guilty of an indictable offence and liable to is guilty of an indictable offence and liable to imprisonment for a term not exceeding 14 years. imprisonment for a term not exceeding 14 years.

CanadaCanada

Original motivation for this legislation was to Original motivation for this legislation was to protect vulnerable peopleprotect vulnerable people

Originally included prohibition on suicide but was Originally included prohibition on suicide but was amended in 1974. amended in 1974.

This legislation is broad – prevents all people (not This legislation is broad – prevents all people (not just physicians) from aiding suicidejust physicians) from aiding suicide

Challenges usually suggest that physicians be Challenges usually suggest that physicians be written in as an exception to (b)written in as an exception to (b)

Challenges to the LawChallenges to the Law

(On six different occasions, (On six different occasions, motions or bills have been motions or bills have been proposed by members of proposed by members of parliament or committees (C-parliament or committees (C-203, C-261, C-385, among 203, C-261, C-385, among others))others))

Many different challenges to Many different challenges to 241(b) in the Supreme Court241(b) in the Supreme Court

Most famous and closest to Most famous and closest to success was the Sue Rodriguez success was the Sue Rodriguez case (1992/3)case (1992/3)

We will examine this case, and We will examine this case, and take special note of the moral take special note of the moral principles underlying the legal principles underlying the legal debatedebate

Sue RodriguezSue Rodriguez

Sue Rodriguez CaseSue Rodriguez Case

40 year old woman living in B.C.40 year old woman living in B.C. Amyotrophic Lateral Sclerosis (A.L.S.) ‘Lou Gehrig’s DiseaseAmyotrophic Lateral Sclerosis (A.L.S.) ‘Lou Gehrig’s Disease ALS – mentally competent while body degeneratesALS – mentally competent while body degenerates In the end, physically unable to swallow, speak, walk or In the end, physically unable to swallow, speak, walk or

move without assistancemove without assistance Requested PAS but illegalRequested PAS but illegal

Challenged s.241(b) of the criminal code on the grounds Challenged s.241(b) of the criminal code on the grounds that it violates ss. 7, 12, & 15 (1) of the Canadian Charter of that it violates ss. 7, 12, & 15 (1) of the Canadian Charter of Rights and FreedomsRights and Freedoms

Supreme Court Decision: s.241(b) upheld in 5-4 decisionSupreme Court Decision: s.241(b) upheld in 5-4 decision Sue Rodriguez died in 1994 with the assistance of a Sue Rodriguez died in 1994 with the assistance of a

physician (who was never charged)physician (who was never charged)

Charter Rights and MoralityCharter Rights and Morality

Charter rights:Charter rights:

Section 7 – Everyone has the right to life, liberty and Section 7 – Everyone has the right to life, liberty and security of the person and the right not to be deprived security of the person and the right not to be deprived thereof except in accordance with the principles of thereof except in accordance with the principles of fundamental justicefundamental justice

Section 12 – Everyone has the right not to be subjected to Section 12 – Everyone has the right not to be subjected to any cruel and unusual treatment or punishmentany cruel and unusual treatment or punishment

Section 15 (1) – Every individual is equal before and under Section 15 (1) – Every individual is equal before and under the law and has the right to the equal protection and equal the law and has the right to the equal protection and equal benefit of the law without discrimination and, in particular, benefit of the law without discrimination and, in particular, without discrimination based on race, national or ethnic without discrimination based on race, national or ethnic origin, colour, religion, sex, age or mental or physical origin, colour, religion, sex, age or mental or physical disability.disability.

Moral Principles Underlying Moral Principles Underlying Legal DebateLegal Debate

Autonomy? Autonomy? Beneficence? Beneficence? Equality/Justice?Equality/Justice?

Which section of the charter seems Which section of the charter seems most appropriate from a moral most appropriate from a moral perspective?perspective?

Hippocratic OathHippocratic Oath

Wolf, “The principles Wolf, “The principles bounding medical bounding medical practice are not practice are not written in stone. They written in stone. They are subject to are subject to reconsideration and reconsideration and societal negotiation societal negotiation over time” (232)over time” (232)

Evaluation of the Evaluation of the Oath?Oath?

Beyond the Hippocratic Beyond the Hippocratic OathOath

Next class we begin our exploration of ethical Next class we begin our exploration of ethical issues raised by new technological and social issues raised by new technological and social developments not anticipated in the original developments not anticipated in the original Hippocratic OathHippocratic Oath

Starting with new technology: cochlear implantsStarting with new technology: cochlear implants

SummarySummary

Case: DianeCase: Diane

Defining Physician-Assisted Suicide (PAS)Defining Physician-Assisted Suicide (PAS)

Drawing the line at PAS:Drawing the line at PAS: Quill, Cassel and MeierQuill, Cassel and Meier WolfWolf

Slippery Slope ArgumentsSlippery Slope Arguments

Case: Sue RodriguezCase: Sue Rodriguez

The Hippocratic OathThe Hippocratic Oath

ContactContactProf. Kirstin BorgersonProf. Kirstin Borgerson

Room Room 359S359S Munk Centre Munk CentreOffice Hours: Tuesday 3-5pm and by Office Hours: Tuesday 3-5pm and by

appointmentappointmentCourse Website: Course Website: www.chass.utoronto.ca/~kirstinwww.chass.utoronto.ca/~kirstin

Email: kirstin@chass.utoronto.caEmail: kirstin@chass.utoronto.ca