Leon Kass on“Death with Dignity and the Sanctity of Life”
MHHS M301/ Phil P383“Perspectives on Health, Disease and Healing”
November 28, 2007
Peter H. Schwartz MD, PhDCore Faculty Member, IU Center for Bioethics
Assistant Professor of Medicine, IUSMAssistant Professor of Philosophy, IUPUI
When 76-year-old Dick Farris of Portland,Ore., was diagnosed with pancreatic cancerin February 2002, he knew what was coming.Both Farris' father and two brothers hadsuccumbed to the illness. "As soon as helearned what it was or suspected, he told thedoctor he wanted out," says Gloria, Farris'wife of 16 years.
Farris lost weight rapidly, developed soresin his mouth so he could not swallow, andhad raging fevers at 105 degrees. "By the firstweekend in March, I was shocked to see howhe was a shadow of what he had been,"Gloria Farris says.
As an Oregon resident, Farris was able toavail himself of the Oregon Death WithDignity Act to hasten his death. The 1994 lawgives Oregon doctors the authority toprescribe controlled substances to mentallycompetent, terminally ill patients who arewithin six months of dying.
Surrounded by his wife and family, Farristook his last breaths. "I said, 'I'll see you in themorning,' " Gloria Farris recalls. "Then he saidOK and drank the rest of [a liquid barbiturate].It was so peaceful. He just went to sleep inmy arms."
"I feel that if the people involved in [opposingphysician-assisted suicide] really understoodhow careful the law is, they would view itdifferently," she says. "I can't believe anyonewould view this as anything but humane andbeautiful."
Marya LucasLegal Times02-16-2005
Distinctions:“Passive euthanasia”
- Refusing treatment- Discontinuing treatment- Extraordinary vs. Ordinary care:
- Extraordinary: Ventilator- Ordinary: Antibiotics- Sustenance: Food and water- How to classify feeding tube?
- Treating pain, suffering (e.g. with morphine)even if it carries some risk of causing death.
Distinctions (continued):“Active euthanasia”
- Physician Assisted Suicide (PAS): Doctorprovides patient with medications to allow herto end her own life. E.g. Oregon’s “Deathwith Dignity” act
- Active euthanasia: Doctor gives medicationthat kills patient. E.g. Holland.
- Kevorkian.
Distinctions (continued):Voluntariness
• Voluntary: Mr. Farris.• Involuntary: Nazis• Non-voluntary (?): Dementia, Schiavo
Today we’ll only consider Voluntary acts, andfocus on the debate over Physician AssistedSuicide (PAS), I.e. Oregon law.
Current American Law and Practice:Two key US Supreme Court decisions:
• 1990: US Supreme Court: Cruzan: Everycompetent adult has the RIGHT to refuse ordiscontinue any treatment
• 1997: Quill v. Vacco (2nd Circ) andWashington v. Glucksberg (9th Circ) There isno Constitutional RIGHT to PAS.– But also it is not unconstitutional for a state
to pass a law legalizing PAS.
Oregon “Death with Dignity” Act
1. A primary-care physician and a consultingphysician must both agree that the patienthas six months or less to live.
2. The patient must make two oral requests (atleast forty-eight hours apart) for drugs to useto terminate his or her life.
3. The patient must wait at least fifteen daysafter the initial oral request, then make awritten request to the physician.
(Munson, pp. 697-8)
Oregon “Death with Dignity” Act (continued),(Munson, pp. 697-8)
4. If either physician thinks the patient has amental disorder or is suffering from impairedjudgment from depression, they mustrecommend the patient for counseling.
5. The patient can terminate the request at anytime during the process.
“…[A] physician is not permitted to assist apatient to die by any means more active thanprescribing medication that can cause deathand indicating the manner in which it can beused.”
“[Questions] emerge, insistently and urgently,from poignant human situations, occurringdaily in hospitals and nursing homes, aspatients and families and physicians arecompelled to decide matters of life and death,often in the face only of unattractive, evenhorrible, alternatives. Shall I allow the doctorsto put a feeding tube into my eighty-five-year-old mother, who is unable to swallow as aresult of a stroke?” (Kass, p. 231)
“Now that it is inserted and she is notrecovering, may I have it removed? Whenwould it be right to remove a respirator,forego renal dialysis, bypass lifesavingsurgery, or omit giving antibiotics forpneumonia? When in the course of my ownprogressive dementia will it be right for mychildren to put me into a home or for me toask my doctor or my wife or my daughter for alethal injection? When, if ever, should I as aphysician or husband or son accede to …such a request?” (p. 232)
Pro PAS based on consent:
“Blows struck in a boxing match or on thefootball field do not constitute assault;conversely, an unwelcome kiss from astranger, because it is an unconsentedtouching, constitutes a battery, actionable atlaw.” (p. 237)
Pro PAS, based on consent (cont.):
“If consent excuses – or even justifies – these‘attacks’ on the body of another, might notconsent excuse – or justify – the ultimate, thatis, lethal, attack and turn murder into merely(unwrongful) homicide? A person can bemurdered only if he personally does not wantto be dead.” (p. 238)
Against PAS, despite consent:
“Indeed, the most abominable practices,proscribed in virtually all societies, are notexcused by consent. Incest, even betweenconsenting adults, is still incest; cannibalismwould not become merely delicatessen if thevictim freely gave permission; ownership ofhuman beings, voluntarily accepted, wouldstill be slavery. The violation of the other isindependent of the state of the will (in fact, ofboth victim and perpetrator).” (p. 238)
Against PAS, despite consent (cont.):
“Is the life of another human being to berespected only because that person (orsociety) deems or wills it respectable, or is itto be respected because it is in itselfrespectable?” (p. 238)
Against PAS, despite consent (cont.):“This latter view squares best with ourintuitions. According to our law, killing thewilling, the unwilling and the nonwilling (forexample, infants or the comatose) are allequally murder. Beneath the human will,indeed, the ground of human will, issomething that commands respect andrestraint, willy-nilly. We are to abstain fromkilling because of something respectableabout human beings as such. But what is it?”(p. 238)
Two separate possible points:
1) Just because a person says that somethingis OK with him, and that person is sane(informed, competent, etc.) by all othermeasures, that doesn’t mean that it’s moralto do what he agrees to or asks. E.g.slavery, incest, and cannibalism.
2) PAS is like slavery, incest, and cannibalismin that it violates human dignity.
Point (1) seems right, but has he proven (2)?
Challenge: What supports (2), i.e. the claimthat PAS violates human dignity?
Need to look more closely at what death withdignity might mean/ involve.
First, is a rejection of medical interventions:“[I]ntubated and electrified, with bizarremechanical companions, confined andimmobile, helpless and regimented, onceproud and independent people findthemselves cast in the roles of passive,obedient, highly disciplined children. Deathwith dignity means, in the first instance, theremoval of these added indignities anddehumanizations of the end of life.” (p. 245)
Second: “…[N]ot all obstacles to dignity areartificial and externally imposed. Infirmity andincompetence, dementia and immobility – allof them of natural origin – greatly limit humanpossibility, and for many of us they will besooner or later unavoidable, …” (p. 245)
Third: “… [T]here is nothing of human dignity inthe process of dying itself, only in the way weface it. At its best, death with completedignity will always be compromised byextinction of dignified humanity; it is, Isuspect, a death-denying culture’s angerabout dying and mortality that expresses itselfin the partly oxymoronic and unreasonabledemand for dignity in death.” (p. 245)
“A death with positive dignity – which mayturn out to be something rare, like a life withdignity – entails more than the absence ofexternal indignities. Dignity in the fact ofdeath cannot be given or conferred from theoutside; it requires a dignity of soul in thehuman being who faces it.” (p. 246)
His list (pp. 248-9)• Be aware that you are dying• Remain an “agent,” not just a “patient”• Maintain professional, personal, social
relationships
“It will, I hope, now be perfectly clear thatdeath with dignity, understood as livingdignifiedly in the face of death, is not amatter of pulling plugs or taking poison.” (p.249).
Responses?How about pluralism about dignity?
Withdrawal/ Refusal of treatment:“About treatment for the actually dying,there is in principle no difficulty. …[C]onsiderations of the individual’s health,activity and state of mind must enter intodecisions of whether and how vigorously totreat if the decision is indeed to be for thepatient’s good.” (p. 250)
(continued, next slide)
“Ceasing treatment and allowing death tooccur when (and if) it will, can, under somecircumstances, be quite compatible with therespect that life itself commands for itself.For life can be revered not only in itspreservation, but also in the manner inwhich we allow a given life to reach itsterminus.” (p. 250)
Any questions raised by his saying this?
My question: Can he have this position alongwith his view of dignity and PAS?
I.e. Is giving up and “allowing death to occur”dignified?
I.e. Can he accept withdrawal of treatment assufficiently dignified without opening thedoor to PAS?
Arguments AGAINST the idea that PAS iscompatible with human dignity:
1) Violation of doctor’s creed: “Elsewhere Ihave argued at great length against thepractice of euthanasia by physicians, partlyon the grounds of bad social consequences,but mainly on the grounds that killingpatients – even those who ask for death –violates the inner meaning of the art ofhealing.” (p. 250)
Arguments AGAINST the idea that PAS iscompatible with human dignity:
2) “Is it really dignified to seek to escape fromtroubles for oneself? Is there, to repeat, notmore dignity in courage than in its absence?”(p. 251)
Arguments AGAINST the idea that PAS iscompatible with human dignity:
3) “Euthanasia for one’s own dignity is, at best,paradoxical, even self-contradictory: howcan I honor myself by making myselfnothing? Even if dignity were to consistsolely in autonomy, is it not anembarrassment to claim that autonomyreaches its zenith precisely as itdisappears?” (p. 251)
Arguments AGAINST the idea that PAS iscompatible with human dignity:
4) “The choice for death is not one optionamong many, but an option to end all options.Socially, there will be great pressure on theaged and the vulnerable to exercise thisoption. Once there looms the legalalternative of euthanasia, it will plague andburden every decision made by any seriouslyill elderly person – not to speak of their morepowerful caretakers – even without the subtlehints and pressures applied to them byothers.” (pp. 251-2)
Arguments AGAINST the idea that PAS iscompatible with human dignity:
5) Who can we ask for help in dying?“Consider [this request’s] double meaning ifmade to a son or daughter: Do you love meso little as to force me to live on? Do youlove me so little as to want me dead? Whatperson in full possession of their own dignitywould inflict such a duty on anyone theyloved?” (p. 252)
“To turn the matter over to non-physicians,that is, to technically competent professionaleuthanizers, is, of course, to completelydehumanize the matter.” (p. 252)
Conclusion:“I also know that when hearts break andpeople can stand it no longer, mercy killingwill happen, and I think we should beprepared to excuse it – as we generally do –when it occurs in this way. But an excuse isnot yet a justification, and very far fromdignity.” (pp. 254-5)
Conclusion (continued):“Thus, when the advocates for euthanasiapress us with the most heartrending cases,we should be sympathetic but firm. Ourresponse should be neither ‘Yes, formercy’s sake’ nor ‘Murder! Unthinkable!’ but‘Sorry. No.’” (p. 255)
Say this to Mrs. Farris…
