Erica Alcantara, Sarah Johansen, Anna Tran, Carissa Voelker, Jessica Wang

BH 411 - Small Group Assignment 3

Group 8
2 June 2014
a) Four Box Analysis:
Medical Presentation
The patient is a 63-year-old Dutch man named Cees van Wendel de Joode who is requesting
euthanasia. He has been diagnosed with amyotrophic lateral sclerosis (ALS), an incurable
neurodegenerative disease.
Medical Indications
Patient: Cees van Wendel de Joode
(Kees)
Diagnosis: amyotrophic lateral
sclerosis (ALS)
Prognosis: there is no cure for ALS.
Goals of therapy: to end Kees
suffering and end his pain.
Futility vs. Utility of Treatment: By
performing euthanasia the goals of
therapy will be met because Kees will
no longer be living in constant pain or
suffering.

Patient Preferences
Kees does not need a surrogate decision maker.
Patient Autonomy: the patient is capable of making his own
decisions. He states he does not want to go to the hospital or
to use a respirator. He fears his wishes will not be taken care
of at the hospital. He wants to request euthanasia while he is
still able to communicate his thoughts.
The patient has verbally requested euthanasia multiple times
and has also given a written request for the treatment written
for him by his wife Antoinette. He views euthanasia as
liberation from his incurable disease.
His wife, primary physician, and another physician, who gave
a second opinion, have been involved in the decision process
and have supported his choice.

Efficacy/Inefficacy: Euthanizing Kees

as per his multiple requests will be the
most efficient way to meet the goals of
therapy.
Quality of Life
The patient is living in constant pain.
He cries when he is touched.
It is increasingly hard for him to move
and he is unable to walk. He must use
a wheelchair in order to be capable of
some mobility.
It is hard for Kees to swallow and
breathe.
Speech is difficult for him, so he needs
his wife to serve as an interpreter in
order to communicate with others.
Kees emotions are harder for him to
control, and he frequently cries.

Contextual Features
Family Impact: Antoinette, Kees wife and caretaker, states it
is becoming increasingly difficult to take care of Kees
because of how fast his disease has progressed in such a
short time.
No conflicts among providers: Kees primary doctor and the
doctor chosen for a second opinion both agree abide to Kees
wishes.
The patient has not had any complaints of being unable to
afford treatment.
Euthanasia is illegal, but the case satisfies conditions for the
physician not to be prosecuted for his actions: there is
hopeless and unbearable suffering with no prospect of cure,
there has been a written request for euthanasia, the physician
has determined that the patient is in the dying phase, and the

physician is also the patients attending medical doctor.

The patient does not perceive his
current state of life as a satisfactory
quality of life.
By performing euthanasia, Kees will
no longer be suffering but will no
longer be living.
Kees condition is only expected to
become worse. If euthanasia is not
performed, he is expected to
eventually die from suffocation as fluid
builds up in his lungs.

b) Consensus Recommendation
We recommend proceeding as per Kees wishes and providing the requested voluntary
euthanasia.The patient has amyotrophic lateral sclerosis (ALS), an incurable disease, and is
suffering immensely day to day. Since both Kees primary physician and another independent
physician have both agreed that he is eligible to receive euthanasia, we would recommend
following the patients wishes to end his suffering.
c) Ethical Argument to Support Recommendation
To provide a rationale for our recommendation to proceed with voluntary euthanasia, we appeal
to the four principles of autonomy, beneficence, nonmaleficence, and justice, as well as the
principle of double effect. We argue that the physician performing assisted death would support
all the principles of autonomy, beneficence, and nonmaleficence. The principle of justice, while
important, does not seem to be a factor in this case as there seem to be no major ramifications
affecting whether other patients are treated differently as a result of Kees receiving treatment. In
utilizing the rationale provided by the principle of double effect, we will argue that the bad effect of
the physicians actions are unintended, that only good effects are intended, that the bad effect is
not a means to the good effect, and that the bad does not outweigh the good effects of the
treatment.
The physician providing euthanasia supports the principles of autonomy, beneficence, and
nonmaleficence. In this case, Kees has repeatedly requested physician assisted death verbally
within a span of a few weeks in between requests. He also made this request in writing and was
evaluated by two different physicians to determine that he was sound of mind and firm in making
this decision. By the principle of autonomy, the physician should respect and follow Kees
preferences and would be morally permitted to administer euthanasia. By the principle of
beneficence, the physician is bound to do only what would be good for the patient. By agreeing to
administer a physician-assisted death via anesthetics and a lethal dose of medication, the
physician would be acting in accordance with what is good for Kees. The physician would do this
by both providing Kees a method for a painless death and the freedom to choose when he would
like to receive the treatment. The ability to choose the timing of his death would relieve Kees of
the stress of not knowing when he would die and allow him to make adequate preparations for his
wife and loved ones after his death. In addition, peacefully dying would eliminate future pain and
suffering from living with ALS. Finally, the principle of nonmaleficence states that a physicians
actions should do no harm. In this case, the ramification of administering euthanasiaKees
peaceful deathis not perceived by the patient, the patients wife, or the two evaluating
physicians as a harm that would cause Kees more pain than benefit. Thus, a physician-assisted
death would be in accordance with the principles of autonomy, beneficence, and nonmaleficence.

The principle of double effect also supports the conjecture that euthanasia for Kees is ethically
permissible. In this case, the bad effect of the treatment, Kees death, is not the sole reason for
providing the treatment. Rather, the intended effect of the euthanasia is to provide Kees a means
to choose a peaceful death devoid of pain and the freedom to decide the moment of his death. As
previously mentioned, both these effects are perceived as good by the patient and are in
accordance with the respect for his autonomy, and so the second condition, that only good effects
are intended, is also met. Furthermore, the patients death is not a means to supporting his
autonomy. Instead, it is out of support of the patients autonomy that a physician providing the
patient with euthanasia is justified. Thus, the bad effect is not the means to the good effect.
Finally, the bad achieved by the outcomes of physician-assisted death do not outweigh the good.
The fact that the patient will die from euthanasia does not outweigh the good of providing the
patient with the assurance for a painless death. This point is further supported by the fact that a
denial of euthanasia would result in an eventual death by ALS as well as continued pain and
suffering due to the illness.
d) Dissenting Viewpoint and Basis for Rejecting It
One argument against proceeding with euthanasia would be the assertion that physician assisted
death violates the sanctity of human life. The argument is that there is a certain inherent value in
human life, and in the act of providing euthanasia; a physician is committing an irreversible wrong
by destroying something of inherent value. In an evaluation of our basis for rejecting this
assertion, we consider both the professional assessment of medical providers and the patients
own perception on his current quality of life. It has been made clear that ALS is an incurable
condition; ALS is causing the degeneration of the patients muscles such that fundamental
actions, such as breathing and swallowing, are rapidly becoming more difficult and painful. In
addition, Kees feels emotional pain from being immobile and a burden to his wife, whom he loves
and is taking care of him. Kees quality of life is unsatisfactory to himself, and he prefers death by
euthanasia as a means for ending his life. In conclusion, while there may be inherent value in
human life, the value of Kees life has been greatly diminished by the rapid progression of his
disease even to the point where Kees sees more value in proceeding with a physician assisted
death than continuing to live. In accordance with what the patient perceives will lead to better
outcomes and respect for patient autonomy, we reject the dissenting viewpoint and continue to
assert that euthanasia is ethically permissible.
Another dissenting viewpoint would be that allowing euthanasia would inevitably lead to various
abuses. There will be a psychological slippery slope as physicians inhibitions against killing are
weakened. That is, if a physician is willing to take the life of a competent adult requesting
euthanasia, that physician will be more likely to take the life of an incompetent person also
suffering or burdening others. In addition, there will be a logical slippery slope ethically permitting
a physician to take the life of a patient as long as values such as respect for autonomy and
compassion for suffering (which are often appealed to in euthanasia) are invoked. Both these
slippery slopes increase the risk of abusing euthanasia, and so the argument is that to prevent
this from happening, euthanasia should not be permitted in the first place. Our basis for rejecting
this argument is that performing euthanasia will not necessarily mean that the physician will be
more likely to take another persons life in a different situation. While we agree that it is
impossible to guarantee there will not be incompetent health care providers practicing medicine,
we maintain that any good physician who abides by the same four principles of autonomy,
beneficence, nonmaleficence, and justice and the principle of double effect will come to an
ethically permissible action in their line of work so long as they actively think and analyze each
case they encounter. In addition, euthanasia does provide some benefits to those who have no
other alternatives to avoid an inevitably painful death, and so the treatment in its entirety should
not be banned on the principle of justice. Prohibiting the practice of euthanasia universally would
be depriving terminally ill patients the right to medical treatments that physicians do have the
technical means to deliver. Allowing euthanasia under very controlled and regulated procedures
offers to only do more good and not harm.

e) Policy Recommendation
(for Dutch physicians faced with requests for voluntary active euthanasia)
If the situation arises where a physician is requested by a patient to perform euthanasia, we
suggest that there is a protocol in place for how to handle the situation and the appropriate steps
to take. It would be helpful to look at some states in the US that currently employ policies of
Physician-Assisted Suicide, and possibly build on these states current policies and adjust them
as needed.
In 2008, the Death with Dignity Act was passed in Washington State. This act is described as:
An adult who is competent, is a resident of Washington state, and has been determined by the
attending physician and consulting physician to be suffering from a terminal disease, and who
has voluntarily expressed his or her wish to die, may make a written request for medication that
the patient may self-administer to end his or her life in a humane and dignified manner..." To be
eligible for consideration, the patient must meet and comply with the following requirements:
Patient eligibility:
18 years of age or older
Resident of Washington
Capable of making and communicating health care decisions for him/herself
Diagnosed with a terminal illness that will lead to death within six months
There is also a very specific protocol that the attending physician must follow:
Physician protocol:
The attending physician must be licensed in the same state as the patient.
The physician's diagnosis must include a terminal illness, with six months or less to live.
The diagnosis must be certified by a consulting physician, who must also certify that the
patient is mentally competent to make and communicate health care decisions.
If either physician determines that the patient's judgment is impaired, the patient must be
referred for a psychological examination.
The attending physician must inform the patient of alternatives, including palliative care,
hospice and pain management options.
The attending physician must request that the patient notify their next-of-kin of the
prescription request.
Last but not least, there is a strict timeline that must be adhered to throughout the process:
Patient request timeline:
First verbal request to physician
15 day waiting period
Second verbal request to physician
Written request to physician
48 hour waiting period before picking up prescribed medications.
Pick up prescribed medications from the pharmacy
Since this act has proven to work successfully in Washington (as well as a few other states that
have similar policies), we have reason to believe that it could be successful for the Dutch
community as well. With trial and error, there could always be certain adjustments made to the
policies that fit their country best as a whole, but our recommendation would be to at least use
Washingtons current policies as a reference and build off of it in regards to best meet the needs
of the patients and physicians.
Citation for specific Death with Dignity requirements listed:
"Death with Dignity Act." Washington State Department of Health. N.p., n.d. Web. 31 May 2014.
<http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/DeathwithDignityAct.aspx>.