2 Bonnie Steinbock: “The Intentional Termination of Life” Steinbock’s ProjectRachels is mistaken in the belief that the AMA doctrine rests on a distinction between “intentionally killing” and “letting die”.As such, arguments showing that the distinction has no moral force do not reveal that adherents to the AMA doctrine are morally confused.The AMA doctrine does not imply support of the active/passive euthanasia distinction: it rejects both.
3 American Medical Association Doctrine: 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. The advice and judgment of the physician should be freely available to the patient and/or his immediate family.
4 Cessation of Treatment & Passive Euthanasia Rachels argues the AMA doctrine forbids “active euthanasia”, and permits “passive euthanasia”.Rachels’ error is in identifying the cessation of life-prolonging treatment with passive euthanasia (“intentionally letting die”).If it were correct to equate the two, then the AMA statement would be self-contradictory, for it would begin by condemning, and end by allowing, the intentional termination of life.But if the cessation of life-prolonging treatment is not always or necessarily passive euthanasia, this problem needn’t arise.
5 Rebuffing RachelsRachels’ Claim: “What is the cessation of treatment […] if it is not ‘the intentional termination of the life of one human being by another’?”There are at least two situations in which the termination of life-prolonging treatment cannot be identified with the intentional termination of the life of one human being by another:Where the patient has refused treatment.Where continued treatment has little chance of improving the patient’s condition and brings greater discomfort than relief.
6 Rebuffing Rachels (cont’d) Case 1: The right to refuse treatment Recall Rachels’ throat cancer patient:Rachels argues: The AMA policy seems to require that such a patient endure a slow, painful death rather than allowing a lethal injection for terminally-ill patients.Why may a doctor cease treatment at the patient’s request, but not provide a patient with a lethal dose at the patient’s request?The patient has a right to refuse treatment – even where the treatment is necessary to prolong life.(This right can be overridden where the patient has dependent children, but not otherwise.)
7 Case 1: The right to refuse treatment (cont’d) Rebuffing RachelsCase 1: The right to refuse treatment (cont’d)If one has the right to refuse life-prolonging treatment, why doesn’t he also have the right to end his life, and obtain help in doing so?The right to refuse treatment is a right to bodily self-determination: in particular, a right to be protected from unwanted interference from others.A “right to die” does not arise as a consequence of this.If we recognized a right to voluntary euthanasia, we would have to agree that people have a right to be killed.There can be a reason for terminating life-prolonging treatment other than “to being about the patient’s death.”
8 Case 2: Little chance of success Rebuffing RachelsCase 2: Little chance of successIn any case, we might ask: what treatment is appropriate?Consider a case where treatment is unlikely to benefit for the patient, but will cause more discomfort than the disease itself.Such treatment is often called “extraordinary.”A treatment that might be considered “extraordinary” in one situation might be merely ordinary in another.“Ordinary” treatment is what a doctor would normally be expected to provide.Failure for a doctor to administer ordinary treatment would constitute neglect of the doctor’s legal obligations.
9 Case 2: Little chance of success (cont’d) Rebuffing RachelsCase 2: Little chance of success (cont’d)“The importance of the ordinary/extraordinary care distinction lies partly in its connection to the doctor’s intention.” (250)“We never kill a baby. … But we may decide certain heroic intervention is not worthwhile.” (250)Recall Rachels’ Down’s syndrome baby:Rachels argues: The AMA policy, strictly interpreted, seems to allow newborn Down’s syndrome babies to die from intestinal blockages, though this is not the reason that parents think it best to let the babies die.Rachels is correct that it is wrong not to operate in the Down’s syndrome case, but such a wrong is not permitted by the AMA policy.
10 Case 2: Little chance of success (cont’d) Rebuffing RachelsCase 2: Little chance of success (cont’d)The AMA statement criticized by Rachels allows only for the cessation of extraordinary means to prolong life when death is imminent.Neither of these conditions is satisfied in the Down’s syndrome example.Death is no more imminent than it is in a case of appendicitis.The removal of the intestinal obstruction is not extraordinary: it is not particularly expensive not does it place an overwhelming burden on others.The chances of success of such an operation are good—though the operation will not alleviate the Down’s syndrome, she will proceed to an otherwise normal infancy.
11 ProblemIf the parents or guardians of the child do not consent to an operation, can the doctor be expected to perform it?“As their legal guardians, parents are required to provide medical care for their children, and failure to do so can constitute criminal neglect or even homicide.” (251)Physicians who comply with these parents’ wishes “could be liable for aiding and abetting, failure to report child neglect, or even homicide.” (251)
12 ConclusionNot performing a painful operation on a patient with little hope of survival is not the intentional termination of life.As such, the permissibility of withholding treatment in such cases has no implications for the permissibility of euthanasia.Not performing a painful operation on a patient with little hope of survival is not the intentional termination of life.
13 Response #1Perhaps it is enough that the doctor in ceasing treatment foresees that the patient will die. That is, perhaps the reason for ceasing treatment is irrelevant to its characterization as the intentional termination of life.Steinbock concedes this is a possibility, but notes Rachels provides no arguments for it.
14 Response #2“If life-prolonging treatment may be withheld, for the sake of the child, may not an easy death be provided for the sake of the child as well?” (251)Steinbock does not deny that death may sometimes be in the patient’s best interests, but argues a quick death is not always preferable to a lingering one:“We must be cautious about attributing to defective children our distress at seeing them linger. Waiting for them to die may be tough on parents, doctors, and nurses—it isn’t necessarily tough on the child.” (252)
15 DiscussionSteinbock equates “extraordinary means” with expense and/or burden placed on others. Rachels leaves the matter unspecified, but I referenced a legal definition that equated it with artificially postponing death. Which do you think the AMA meant? Which makes more sense?Steinbock argues that parents of a child who refuse ordinary treatment to save the child’s life act in a morally impermissible manner. But if a person has the right to refuse treatment, why doesn’t the parent of a child have the same right regarding the child?