EUTHANASIA

Euthanasia

Euthanasia directly or indirectly bringing about the

death of another person for that persons sake.
good death

Killing vs.
Letting Die

Active Euthanasia performing an action that directly

causes someone to die. Killing.
e.g. giving a patient a lethal injection
mercy killing illegal; condemned by medical
profession

Passive Euthanasia allowing someone to die by not

doing something that would prolong life. Letting die.
e.g. removing a feeding tube or ventilator, failing to
perform surgery, refraining from giving life-saving
antibiotics.
Legal; endorsed by medical profession

Killing vs.
Letting Die

Intuitively, active euthanasia is inherently morally worse

than passive euthanasia. The AMA agrees:
The intentional termination of the life of one human
being by another -mercy killing - is contrary to that for
which the medical profession stands and is contrary to the
policy of the American Medical Association. The
cessation of the employment of extraordinary means to
prolong the life of the body when there is irrefutable
evidence that biological death is imminent is the decision
of the patient and/or his immediate family.
Rachels and Brock will each examine this intuition.

Euthanasia
and Consent

Voluntary Euthanasia euthanizing a competent patient

voluntarily agrees to euthanasia.
Communicated while competent or with an advance
directive/living will.
When folks ask whether euthanasia is morally
permissible, they are usually asking whether voluntary
active euthanasia is permissible that is, whether a doctor
can euthanize a competent patient who genuinely wants to
die.

Euthanasia
and Consent

Nonvoluntary Euthanasia euthanizing an incompetent

patient without an advanced directive at the behest of
his or her decision-makers.
Family, physician, etc. make the decision

Legally, this can get complicated see, for example, the

Terri Schiavo case.

Involuntary Euthanasia euthanizing a competent

patient who has not voluntarily agreed to euthanasia.
Everyone pretty much agrees that involuntary euthanasia
is wrong.

PhysicianAssisted
Suicide (PAS)

Physician-assisted suicide is usually thought to be

morally equivalent with voluntary active euthanasia.

Voluntary
Active
Euthanasia
(and PAS)

Kinds of Arguments in Favor:

Autonomy: respecting autonomous persons means
respecting their autonomous decisions.
Beneficence: if someone is dying a painful death and
nothing will save them, why should they have to endure
the pain?

Voluntary
Active
Euthanasia
(and PAS)

Kinds of Arguments Against:

moral difference between killing and letting die
slippery slope to wanton disregard for human life

RACHELS,
ACTIVE AND
PASSIVE
EUTHANASIA

The
Difference
Thesis

The Difference Thesis All else being equal, killing

someone is morally worse than letting them die.

Rachels:

First goal: To argue that The Difference Thesis is false.

Second goal: To argue that active euthanasia is better
than passive euthanasia (at least in most cases).

Killing vs.
Letting Die
Some Cases

Cases of killing that might come to mind: shooting of

Philando Castile, shooting of Trayvon Martin, victims of
Jack the Ripper, assassination of JFK, armed robberies,
school shootings
Cases of letting die that might come to mind: Terri
Schiavo, hospice patients, infants with congenital
diseases, disaster relief

Rachels
hypothesis:

The intuition that killing is worse than letting die stems

from the fact that the cases of killings that we are prone
to think of involve bad, but non-essential,
characteristics.
Cases of letting die that we think of usually involve
good motives and have, all things considered, good
consequences.
By contrast, killings typically have bad motives, bad
consequences, and highlight our failures as a society (e.g.
racism, failure to care for the mentally ill, failure to keep
our children safe)

Killing vs.
Letting Die

In order to determine whether killing is worse than

letting die, we should compare cases with the same nonessential features. No comparing serial killers to hospice
nurses!

The Bathing
Heir Cases:

Smith stands to gain a large inheritance if anything

should happen to his six-year-old cousin. One evening
while the child is taking his bath, Smith sneaks into the
bathroom and drowns the child, and then arranges
things so that it will look like an accident.
Jones also stands to gain if anything should happen to
his six-year-old cousin. Like Smith, Jones sneaks in
planning to drown the child in his bath. However, just
as he enters the bathroom Jones sees the child sloop and
hit his head, and fall face down in the water. Jones is
delighted; he stands by ready to push the childs head
back under if it is necessary, but it is not necessary.
With only a little thrashing about, the child drowns all
by himself, accidentally, as Jones watches and does
nothing.

The Bathing
Heir
Argument

1.

Jones letting his cousin die is no better than Smith

killing his cousin.

2.

If Jones letting his cousin die is no better than Smith

killing his cousin, then the difference thesis is false.

3.

Therefore, the difference thesis is false.

P1 Rationale:

Suppose Jones pleaded, in his own defense, "After all,

I didn't do anything except just stand there and watch
the child drown. I didn't kill him; I only let him die."
Again, if letting die were in itself less bad than killing,
this defense should have at least some weight. But it
does not.

P2 Rationale:

Now Smith killed the child, whereas Jones "merely" let

the child die. That is the only difference between them.
Did either man behave better, from a moral point of
view? If the difference between killing and letting die
were in itself a morally important matter, one should say
that Jones's behavior was less reprehensible than
Smith's. But does one really want to say that? I think
not.

The Terminal
Illness Cases:

A patient is terminally ill with cancer. He is competent,

but in a lot of pain. He wants to die. His doctors
withdraw his feeding tube to let him die. Of course, he
wont die right away; after roughly 72 hours he dies of
thirst.
A patient is terminally ill with cancer. He is competent,
but in a lot of pain. He wants to die. His doctors
administer a painless lethal injection, and the patient
dies quickly and painlessly.

The Terminal
Illness
Argument

1.

In most cases active euthanasia leads to the same

result as passive euthanasia, but with less suffering.

2.

If in most cases active euthanasia leads to the same

result as passive euthanasia but with less suffering,
then the difference thesis is false.

3.

Therefore, the difference thesis is false.

P1 Rationale:

Passive euthanasia requires not only continued pain

from the illness, but also the additional pain of
dehydrating or starving. Active euthanasia requires
neither of these things.

P2 Rationale:

Why should anyone favor letting dehydration and

infection wither a tiny being over hours and days? The
doctrine that says that a baby may be allowed to
dehydrate and wither, but may not be given an injection
that would end its life without suffering, seems so
patently cruel as to require no further refutation.

Scope of
Rachels
Conclusion

This argument does not establish that active euthanasia

is morally permissible. It only establishes that active
euthanasia is better than passive. If both kinds of
euthanasia are wrong, then active euthanasia is morally
impermissible, but still less wrong than passive
euthanasia.

BROCK,
VOLUNTARY
ACTIVE
EUTHANASIA

Brock

Two Goals:
First to argue that there is no essential physical
difference between acts of killing and acts letting die.
Second to argue that the likely benefits of a legal policy
that allows for active euthanasia outweigh the possible
costs.

Compare
Strategies

Rachels: Consider cases that are alike with respect to all

features except whether the act in question is a killing or
an allowing to die. If the two cases are morally on par,
then there is no essential moral difference between
killing and letting die (because, if there were a moral
difference, then the cases would not be morally on-par).
Brock: Consider cases that are alike with respect to all
features except whether the agent performing the action
in question is justified in performing it. If one case is an
allowing to die and the other case is a killing, then there
is no essential physical difference between killing and
letting die (because if the difference were essentially
physical, then the same physical situation could not be
sometimes a killing and other times a letting-die)

What kind of
physical
difference?

Widely shared view: killing is an action and letting die

is an omission.
Directly/indirectly bringing about a death. When
we draw this distinction, we talk about what things are
like in the physical world.

The
Respirator
Cases

A patient terminally ill with ALS diseaseis

completely respirator dependent with no hope of ever
being weaned. She is unquestionably competent but
finds her condition intolerable and persistently requests
to be removed from the respirator and allowed to die.
Her physician removes her from the respirator.
Does the physician kill her, or let her die?

The
Respirator
Cases

Suppose the patient has a greedy and hostile son who

mistakenly believes that his mother will never decide to
stop her life-sustaining treatment and that even if she
did her physician would not remove her from the
respirator. Afraid that his inheritance will be dissipated
by a long and expensive hospitalization, he enters his
mothers room while she is sedated, extubates her, and
she dies.
Does the son kill her, or let her die?

The
Respirator
Cases

Most people have the intuition that the greedy son kills
her, but that the physician merely lets her die.

The
Argument
against the
Killing/
Letting Die
Distinction

1.

If a physician extubating a patient from a respirator is

merely letting her die, then a greedy son extubating his
mother from a respirator is merely letting her die.

2.

A greedy son extubating his mother from a respirator

is not merely letting her die.

3.

Therefore, a physician extubating a patient from a

respirator is not merely letting her die.

P1 Rationale:

Theyre the same physical action! Granted, there are

some substantial moral differences between the two
cases, but were considering the view that the difference
between killing/letting die is a physical difference.
These cases exhibit no physical difference. So, if one is
a letting-die, then so is the other.

P2 Rationale:

Suppose the son says in his defense, I didnt kill her, I

merely allowed her to die. It was her ALS disease that
caused her death! Do you buy it? Probably not.

Possible
Responses

3 Options
Reject premise 1; perhaps the difference between killing
and letting die is not a physical difference.
Reject premise 2; the son merely let his mother die.
Accept conclusion; the physician killed the patient.

Possible
Responses

Serious problem with option 2:

It entails that all kinds of murders are just letting die.
Suppose I remove all of the oxygen from your room. You
suffocate. I didnt kill you I merely let you die. It was
your oxygen dependence that killed you!

Options 1 and 3 both require us to abandon the typical

understanding of the killing/letting die distinction (but
maybe thats okay!)
If we reject premise 1, then we have to appeal to
something non-physical to explain the difference between
killing and letting die. Perhaps, for example, it has
something to do with an agents intentions. The doctor
has good intentions, the greedy son has bad intentions,
etc.
If we accept the conclusion, then there is no such thing as
merely letting die. There is only killing.

Possible
Responses

If we take Option 1 or Option 3, then it seems like there

is not a substantial difference between active and
passive euthanasia.
If the difference between killing and letting die has
something to do with intentions, then even active
euthanasia ought to be considered letting die because
the physician has good intentions.
If there is only killing, then even passive euthanasia is
killing, so whats supposed to be uniquely wrong with
active euthanasia?
In either case, the intuition that killing is worse than
letting die is jeopardized.

ARRAS,
PHYSICIANASSISTED
SUICIDE: A
TRAGIC VIEW

Two kinds of
potential for
abuse of
PAS

Broad Applicability: The reasoning behind PAS also

lends support for active euthanasia, and for making PAS
an option for too broad a range of candidates.
No Safety Net: it is unlikely that the safeguards put in
place to prevent abuses of PAS will be fully realized.

Broad
Applicability

[A] socially sanctioned practice of PAS would in all

likelihood prove difficult, if not impossible, to cabin
within its originally anticipated boundaries. Proponents
of legalization usually begin with a wholesomely
modest policy agenda, limiting their suggested reforms
to a narrow and highly specified range of potential
candidates and practicesBut the logic of the case for
PAS, based as it is upon the twin pillars of patient
autonomy and mercy, makes it highly unlikely that
society could stop with this modest proposal.

The Broad
Applicability
Argument
against PAS

1.

If a social policy allowing for PAS is justified, then

nearly anyone is a potential candidate for PAS.

2.

It is not the case that nearly anyone is a potential

candidate for PAS.

3.

Therefore, a social policy allowing for PAS is not

justified.

P1 Rationale

If autonomy is the prime consideration, then additional

constraints based upon terminal illness or unbearable
pain, or both, would appear hard to justify. Indeed, if
autonomy is crucial, the requirement of unbearable
suffering would appear to be entirely subjective. Who
is to say, other than the patient herself, how much
suffering is too much? Likewise, the requirement of
terminal illness seems an arbitrary standard against
which to judge patients own subjective evaluation of
their quality of life.
we can expect that many candidates will be perfectly
ambulatory and far from the dreaded scene of painful
terminal illness depicted by advocates.

P2 Rationale

We look backwards and find cases where there is

genuine candidacy for PAS, thinking this justifies the
view. But think of all the cases in which PAS is
seemingly unjustified, but would nonetheless be allowed
under this policy: psychiatric disorders, early stage HIV
or Alzheimers, etc.

The Active
Euthanasia
Argument
against PAS

If a social policy allowing for PAS is justified, then a

social policy allowing for active euthanasia is justified.
A social policy for active euthanasia is not justified
Therefore, a social policy allowing for PAS is not
justified.

P1 Rationale

Some people would seek PAS if they werent physically

impaired (For example, read about the case of Dax
Cowart). So, a PAS policy without an Active
Euthanasia policy would discriminate against the
physically impaired; indeed, these patients are the
worst off

P2 Rationale

An Active Euthanasia policy is not justified because of

potential for abuse (for the reasons outlined under No
Safety Net, which are coming up next).

No Safety Net

No Safety Net: it is unlikely that the safeguards put in

place to prevent abuses of PAS/Active Euthanasia will
be fully realized.
Henceforth Ill just say PAS, but in what follows
everything that applies to PAS also applies to active
euthanasia.

People generally agree that the following three

conditions are necessary for a socially justifiable PAS
policy:
a) Requests for death must be voluntary
b) All reasonable alternatives must have been explored
c) A reliable system of reporting all cases must be
established in order to effectively monitor cases of PAS.
) Arras is a social pessimist he doubts that these
conditions can genuinely be met.

The Policy
Abuse
Argument
against PAS

1.

If a social policy allowing for PAS is justified, then

PAS will always be voluntary, reasonable alternatives
will always be explored, and cases of PAS will always
be reported.

2.

It is not the case that PAS will always be voluntary,

reasonable alternatives will always be explored, and
cases of PAS will always be reported.

3.

Therefore, a social policy allowing for PAS is not

justified

P1 Rationale

No one thinks that PAS policy should be unrestricted;

everyone thinks these things are important

P2 Rationale

Not voluntary
we now live in the golden age of treating depression, but
the lead age of diagnosing it Physicians not adequately
trained to recognize it. If patients are depressed, then
consent to PAS is not voluntary.

P2 Rationale

Not all reasonable alternatives

Its already the case that people dont all have access to
the same alternatives. Poor places have little access to
basic care, let alone sophisticated care for chronic pain.
Doctors might encourage patients to opt for PAS before
exploring all alternatives because our system encourages
doctors to spend little time with patients, and palliative
care is time-consuming. (problem compounded with poor
patients).
Surely we shouldnt prevent the poor from PAS, but if all
reasonable alternatives cant be explored, then we have to.

P2 Rationale

Wont be reported
As the Dutch experience has conclusively demonstrated,
physicians will be extremely loath to report instances of
PAS and active euthanasia to public authorities, largely
for fear of bringing the harsh glare of publicity upon the
patients families at a time when privacy is most needed.
Only 30-50% of cases are reported in the Netherlands.
How can we purport to regulate it if we dont know about
it?

Killing vs.
Letting Die,
Revisited

Arras: Whatever the outcome of our long-standing

conceptual skirmishes bearing on the intrinsic
differences between PAS, [active] euthanasia, and
[passive euthanasia], the crucial question remains
whether any of the purported distinctions between these
activities constitute important differences for purposes
of social policy.
Among the conceptual skirmishes that Arras is referring
to are those raised by Rachels and Brock. So, even if
Rachels, Brock, and the like are correct, Arras thinks there
is still good reason to disallow PAS/active euthanasia as a
matter of public policy we just arent in a position to
regulate PAS and active euthanasia, but passive
euthanasia is, to a great extent, self-regulating.

The
Social Difference
Argument for
Prohibiting Active
Euthanasia and
PAS.

1.

All else being equal, a social policy prohibiting

passive euthanasia is worse than a social policy
prohibiting active euthanasia and PAS.

2.

If all else being equal, a social policy prohibiting

passive euthanasia is worse than a social policy
prohibiting active euthanasia and PAS, then active
euthanasia and PAS should be illegal even if there is
no intrinsic difference between killing and letting die.

3.

Therefore, active euthanasia and PAS should be illegal

even if there is no intrinsic difference between killing
and letting die.

P1 Rationale

Passive while we should definitely worry about the

possibility of error, neglect, and abuse in the context of
allowing patients to die, it is at least somewhat
comforting to realize that just about every patient in this
category must be very badly off indeed.
Active & PAS a form of unconstitutional
discrimination against the mentally ill & poor

P2 Rationale

The reason for denying patients AE & PAS is not that

there is a moral or physical difference in the relevant act
types its because PE is really hard to abuse, and in
our society we need to seriously worry about the
likelihood of abuse. Perhaps some people will fall
through the cracks if we prohibit PAS and AE, but not
as many as will if we allow them.

P2 Rationale

There are those few unfortunate patients who truly are

beyond the pale of palliative, hospice, and psychiatric
care. The opponents of legalization must face up to this
suffering remnant and attempt to offer creative and
humane solutions. One possibility is for such patients to
be rendered permanently unconscious by drugs until
such time, presumably not a long time, as death finally
claims them. [Kim note This is puzzling -- how is this
better???]
Other options take own lives, either traditionally or by
requesting sedation while they starve themselves.
Others will have doctors that are willing to help, despite
the risk.
[Kim note Dont these all seem like bad options?]

PATIENT
AUTONOMY

Patient
Autonomy

Autonomy a persons rational capacity for selfgovernance or self-determination.

Plausible Moral Norm:
The Autonomy Principle autonomous persons should
be allowed to exercise their capacity for selfdetermination.

This leads to

The Patient Autonomy Principle autonomous patients

should be allowed to make decisions about their own
medical care.

What are some examples of situations in which a person

might legitimately be denied the ability to exercise his or
her will?

Paternalism

Paternalism overriding a persons actions or decisions

for their own good.
Weak Paternalism overriding the actions or decisions of
a nonautonomous person.

Not usually controversial.

Strong Paternalism overriding the actions or decisions

of an autonomous person

Often controversial.

Possible views about Strong Paternalism:

Its never okay. The (Patient) Autonomy Principle trumps
everything.
Its sometimes okay, i.e., when the person would consent in
ideal circumstances.
Its sometimes okay, i.e., when the paternalistic act is
balanced out by the welfare it promotes (an act that costs a
little autonomy for a lot of benefit is okay, an act that costs
a lot of autonomy for a little benefit is not).

Two Modern
Cases

Wannabes and Dax Cowart

Wannabes

Wannabe a person who desires to have a healthy limb

amputated.
I feel like an amputee with natural prostheses theyre my legs,
but I dont want to get rid of them they dont fit my body
image
I felt like I was in the wrong body; that I am only complete
with both my arm and leg off on the right side.

Are Wannabes Irrational?

Just because a patients beliefs about the affected limb have been
arrived at irrationally does not mean that the patient is irrational.

Parallel with Jehovahs Witnesses refusing blood transfusionsCompetence is undermined only by unreasonable practical
reasoning, not by impaired belief-fixation or theoretical
reasoning.

Is denying amputation to wannabes in their best interest?

The internet sites run by wannabes often discuss relatively
painless and safe ways of amputating limbs, or damaging them
sufficiently to ensure that surgeons have no choice but to
amputate.

Wannabes

First objection: Amputation wont bring lasting relief.

Reply: The (limited) evidence available suggests that
wannabes experience a lasting increase in wellbeing.

Disanalogy with cosmetic surgery

Second objection: Amputation isnt the only relief;

psychotherapy could help.
Reply: The (limited) evidence available suggests that
psychotherapy does not reduce the intensity of the desire
for amputation.

Further Reading:
http://www.philosophy.ox.ac.uk/__data/assets/pdf_file/0
016/1087/amputees.pdf

Dax Cowart

Dax & Dad in an accident caused by a gas leak & ignition in

Kilgore, TX.
Stranger kills Daxs cries, calls for ambulance. Dax asks for
strangers gun, but stranger refuses.
Dad dies on way to hospital. Dax insists he wants to die, but they
keep him alive. He is driven to an advanced burn unit in Dallas.
He continues to insist on death, and refuses treatment.
He loses both hands, eyes, and ears, but is kept alive and treated.
Continues to refuse treatment. Found to be mentally competent
over and over. Was forcibly treated for 10 months. Treatment
included frequent bandage removal and replacement and being
dipped in chlorine, which felt like being skinned alive on a
regular basis.
Provided with only a modest supply of painkillers. Denied access
to means of communication by which he might seek legal
assistance. Attempted to commit suicide several times, but was
prevented each time.
Today, Dax reports that he is satisfied with his life. Nonetheless,
he insists that he would rather have died than endure it all.

The upshot of
these cases:

A lot of people have the intuition that doctors should not

be required to remove healthy limbs, but that Dax
should have been allowed to die. This is an apparent
conflict; since BIDD patients are competent, it is
strongly paternalistic to deny them the procedure they
seek, and yet that same strong paternalism seems
inappropriate in the Dax case.

GOLDMAN,
THE REFUTATION
OF MEDICAL
PATERNALISM

Goldman

Main Goals:
Object to the view that medical paternalism is justified by
the welfare it promotes.
Argue for the view that medical professionals ought to
honor patients autonomy.

First Goal

So, whats the argument that Goldman is objecting to?

The Argument for Medical Paternalism
1. Medical paternalism minimizes harm to patients.
2. If medical paternalism minimizes harm to patients, then
medical paternalism is justified.
3. Therefore, medical paternalism is justified.

P1 Rationale

Example of medical paternalism: withholding

information from a patient. Why might such a practice
be justified? Sometimes disclosure leads to depression,
physical deterioration, or selection of inoptimal
treatment. So, disclosure in these cases is detrimental to
a patients health and even hasten their death. Health
and prolonged life can be assumed to have priority
among preferences among people. So, worsening heath
or hastening death can be assumed to be contrary to
patients value orderings.

P2 Rationale

Harm is bad, etc.

P1 objection:

Harm a person is harmed when a state of affairs below

a certain level on his preference scale is realized rather
than one higher up.
If harm is understood in this way, then P1 is false.
Why?

Its false that everyone has health and prolonged life at the
top of their preference ordering.

Goldmans
Objection to
P1

Its false that everyone has health and prolonged life at the top of their
preference ordering.
First example: if it were true, then we should spend our entire federal
budget on health-related areas.
Second example: if it were true, then all wars (even defensive ones) are
unjustified. Thats ridiculous; anything worth living for is worth dying
for (Camus). Preserving the values that make life worth living is worth
the risk of life itself.
Third example: we engage in risky activities for far less righteous
reasons. We work too hard, smoke, exercise too little, eat junk food, etc.
even when we know theyre bad for us. Quality and significance of ones
life may take precedence over maximal longevity, e.g., a person with a
heart condition decides important unfinished projects take priority iver
increased risk to health. Since peoples lives derive meaning and
fulfillment from their projects and accomplishments, a persons risking a
shortened life for one more fulfilled might well justify actions detrimental
to his health. Its quality of life that counts not just being alive.

Consider again the case of withholding information. In light of this objection,

it seems that withholding information about the severity of their condition can
harm them inasmuch as they may have used the information to do more
valuable things before their death or incapacitation.

Many people are willing to endure frustration, suffering, and depression in

pursuit of accomplishment.

Second Goal

The Argument for Honoring Autonomy

Autonomy is valuable independent of the welfare it
promotes.
If autonomy is valuable independent of the welfare it
promotes, then medical professionals should honor patient
autonomy.
Therefore, medical professionals should honor patient
autonomy.

P1 Rationale

The Experience Machine

spouse matching
Upshot: Autonomy/self-determination/freedom of
choice is so important that normally no amount of other
goods, pleasures, or avoidance of personal evils can take
precedence. If happiness/pleasure were all that
mattered, then people would be irrational to refuse the
experience machine or decline a spouse-match.
However, its not irrational. So, happiness/pleasure
arent all that matter autonomy is intrinsically
valuable. We value free choice regardless of its effects.

P2 Rationale

If autonomy is really that important, then it should not

be taken away.
Objections?

ACKERMAN,
WHY DOCTORS
SHOULD
INTERVENE

Two Goals:

Argue against views in which honoring patient

autonomy is understood as noninterference (e.g.,
Goldmans argument).
Argue for the view that honoring patient autonomy
ought to be understood as cooperation.

Honoring
Autonomy by
Noninterference

Noninterference a doctors obligation to give weight

to the considered opinions and choices of patients, and
to refrain from obstructing their actions.
Ackerman while honesty, confidentiality, patients
rights are important considerations are important
features of respect for patient autonomy, they are not the
only features;
Beauchamp and Childress: To respect autonomous
agents is to recognize with due appreciation their own
considered value judgments and outlooks even when it is
believed that their judgments are mistaken
Ackerman: When respect for personal autonomy is
understood as noninterference, the physicians role is
dramatically simplified. The doctor need be only an
honest and good technician, providing relevant
information and dispensing professionally competent
care.

First Goal

The Argument against Noninterference

1.

Serious constraints upon autonomous behavior are

intrinsic to the state of being ill.

2.

If serious constraints upon autonomous behavior are

intrinsic to the state of being ill, then noninterference
does not honor patient autonomy.

3.

Therefore, noninterference does not honor patient

autonomy.

P1 Rationale

Features of Autonomous Behavior:

Governed by the agents plan of action

The plan of action has been formulated through the agents

own deliberation and reflection, which is guided by
information gathering and priority setting.

Voluntary and intentional

Based on choices, guided by life plans.

Constraints on autonomy: can be physical (prison) or

cognitive (lack of information say, if side effects of a
treatment are not disclosed); lack of ability to
understand information say, if the side effects are
disclosed, but the patient doesnt understand.)

Patients as
Nonautonomous

Sick people are not equipped for gathering relevant information (and so
patients actions are not properly governed by a plan of action).
Without adequate medical understanding, the patient cannot assess his or her
condition accurately.

If you cant assess your condition accurately, you cant make relevant decisions.
Compare: Youre packing for a trip to Sydney. Since its summer in the southern
hemisphere, you pack your swimsuit, shorts, and lots of sunscreen. You arrive, cold,
in Sydney, Canada. You did some planning, but your lack of understanding led you
to pack the wrong things. Your arriving in Nova Scotia during winter with
swimwear is not a result of you being irrational you just didnt understand which
Sydney you were going to. If you had known it was Sydney, Australia you would
have made different packing decisions.

Even if sick people could properly formulate a plan of action, it is difficult for
sick people to set and maintain life goals (and so patients actions are not
properly voluntary).
An illness may not only temporarily obstruct long-range goals; it may need
permanent and drastic revision in the patients major activities, such as working
habits. Patients may also need to set limited goals regarding control of pain,
alteration in diet and physical activity, and rehabilitation of functional impairments.
They may face considerable difficulties in identifying realistic and productive
goals.
Psychological states such as anxiety, denial, depression, guilt, and fear, as well as
societal and cultural pressures, can each contribute to a patients inability to set
productive goals.

Examples:

Case 1: An 18-year-old dying from aggressive and

extensively metastasized cancer has two options: die
peacefully, or receive intravenous feedings (at the risk of
causing an intestinal blockage and further aggravating the
cancer) so that he can receive chemotherapy that, at best,
will extend his life by a few months. Despite the doctors
repeated attempts to explain the risks and benefits of each
option, the patient would only reply that he wanted to do
whatever was necessary to get better.
Case 2: A middle-aged woman with a history of ovarian
cancer in remission returned for a biopsy. Due to
complications from the biopsy, she had to be placed in a
respirator for several days. She became severely
depressed and refused further treatment (which was
entirely out of character for her she was previously fully
committed to treatment). The medical staff stalled for
time rather than honoring her overt wishes, and her
condition as well as her mental state improved.

Examples:

Case 3: A patient refuses neurosurgery to address a brain

tumor for fear that it would cause lasting cosmetic damage,
but consented to chemotherapy. He became comatose and
his family proceeded with the surgery. The tumor turned
out to be benign, but he died from complications resulting
from a delay in surgery.
Case 4: A phase 1 clinical trial is the only remaining option
for a 12-year-old boy with extensive cancer. The patients
treatment had been difficult, and he confided in the saff that
he desired to quit further therapy and go home. However,
his parents denied the hopelessness of his condition,
insisting that God would save their child. Out of respect
for his parents, the child refused to openly object to further
treatment. The trial was not effective, and the patient died.
Furthermore, clinical observation suggests that many
patients relinquish their opportunity to deliberate in
deference to the doctors expertise (Whatever you think,
Doc!).

P2 Rationale

If serious constraints upon autonomous behavior are

intrinsic to the state of being ill, then noninterference
does not honor patient autonomy.
If there are such constraints on autonomy, then patients
cannot be expected to make the best choices even by their
own lights. Weve been thinking of paternalism as what
the doctor wants versus what the patient wants, but it
seems like in a broad class of cases its what the patient
says they want right now versus what theyd want if they
were able to properly think about it. We want to think of
autonomy as what the person wants when theyre able to
see the big picture. Since these two what the sick
patient thinks they want versus what the patient would
want if they were better able to think through the relevant
information can come apart, there is reason to think that
noninterference deferring to the sick patients judgment
fails to honor patient autonomy.

Second Goal

The Argument for Cooperation

1. Psychological and social constraints impair patient
autonomy.
2. If psychological and social constraints impair patient
autonomy, then patient autonomy is best served by
cooperation.
3. Therefore, patient autonomy is best served by
cooperation

Cooperation psychologically reproducing in the mind

of the doctor, insofar as that is possible, the meaning the
patients illness has for him so that the doctor can assist
patients in restoring control over their lives.

P1 Rationale

See Patients as Nonautonomous slide

P2 Rationale

If autonomy is important to preserve, and if illness

inhibits autonomy, then part of a doctors goal in
treating a patient is restoring the patients autonomy.
Restoring a patients autonomy requires knowing about
his or her psychological and social situation that is, it
requires Cooperation.
Objections?