Solomon Blaylock
CULTURAL STUDIES: ETHICS
Dr. Timothy Madigan
15 December 2008
Eleanor, a married woman in her early thirties, was dying. In the process of giving birth to a child her bleeding had become uncontrolled and the lack of blood had left her frail but conscious. She could only communicate by blinking. Eleanor’s doctors informed her that the sole way in which her bleeding could be brought under control was by means of a blood transfusion. Eleanor was one of Jehovah’s Witnesses, a religious group whose tenets include a prohibition against blood transfusions. She blinked twice, indicating that she did not want the treatment. Her husband was present and was asked four times by the attending physicians to reconsider a document that he and his wife had signed beforehand forbidding the use of blood. He refused and Eleanor died. “I understood how serious it was every time,” the husband later told reporters, “But God is serious too. He does promise resurrection and he does ask his servants to abstain from blood” (Childress 223-224).
Carrie was a young medical professional who came out of an automobile accident in a coma, sustaining multiple compound fractures of both legs and arms, facial fractures, and lacerations. A tracheotomy was performed and Carrie was put on a respirator. Needed orthopedic surgery was delayed as doctors waited for her condition to stabilize. In three weeks Carrie emerged from the coma and appeared to be alert, but could barely move a muscle—the accident had rendered her a quadriplegic and unable to speak. She was able, however, to understand her situation and communicate with slight muscle movements. She began signaling to her parents that she wished to be removed from the respirator. The doctors convinced Carrie’s parents to move her to a rehabilitation center where she continued to indicate to doctors, nurses, and even her minister that she wished to be allowed to die. She was being fed by means of a tube inserted into her small intestine and could not eat, swallow, smell, laugh, or cry. Her face bore a constant grimace of pain. In spite of the fact that the attending physicians agreed Carrie’s case represented “the worst possible scenario of someone being trapped in her own body,” her parents were informed that if they pursued legal action to remove their daughter from the respirator that they would be charged with murder. After contracting a lung infection, Carrie survived for another four weeks during which she developed meningitis and eventually died after having several seizures (Burnell 71-73).
There are scores of similar cases discussed in medical journals, online resources, and books on patients’ rights, with all manner of variations and nuances. A seemingly clearheaded patient inexplicably refuses lifesaving medical treatment, needed therapies are rejected for religious reasons, unconscious or developmentally disabled individuals are spoken for by spouses or parents only to have their decisions overturned by the courts, otherwise rational individuals demonstrate a state of complete denial over the seriousness of their conditions, and sometimes people who have lived long and productive lives simply decide that they no longer want to pursue treatment. Innumerable philosophical and ethical dilemmas are raised by such cases, but they may be generally distilled down to one basic question: Is it right to allow a human being to choose to die?
In this paper I will put a still finer point on the question and leave aside cases involving legal minors. I will argue that adults of legal age should never under any circumstances be compelled by the medical establishment or the state to accept lifesaving medical treatment. I will further argue that such adults, when certain strict legal criteria are met, should be permitted to request and doctors permitted to administer euthanasia, though doctors should be no means be legally compelled to do so.
In On Liberty, John Stuart Mill lays out some basic tenets of personal liberty:
There is a sphere of action in which society, as distinguished from the individual, has, if any, only an indirect interest; comprehending all that portion of a person’s life and conduct which affects only himself, or if it also affects others, only with their free, voluntary, and undeceived consent and participation….This, then, is the appropriate region of human liberty….the principle requires liberty of tastes and pursuits; of framing the plan of our life to suit our own character; of doing as we like, subject to such consequences as may follow: without impediment from our fellow creatures, so long as what we do does not harm them, even though they should think our conduct foolish, perverse, or wrong.
This definition of personal human freedom is simple, straightforward, and intuitive; it will underpin my contentions in this paper. Many people—and one would assume Americans in particular—would doubtless say that they agree with Mill’s take on liberty, at least in principal. But the devil is always in the details, and this is certainly true where lifesaving medical treatment or euthanasia are involved. In the course of discussing the legal right of patients to refuse treatment, Robert M. Veatch, Professor of Medical Ethics at Georgetown University, notes in Death, Dying, and the Biological Revolution:
Many commentators, including spokespersons for the American liberal
legal system, have given [patient] autonomy priority over the concern for
promoting the welfare of competent individuals. In this regard, the
American liberal tradition is in direct conflict with the more paternalistic Hippocratic ethical tradition of physicians, which commits the physician to doing what he thinks will benefit the patient even in cases where the patient thinks otherwise.
How one defines “benefit” in this context is central to the question of medical paternalism. L. S. Lim, in an essay revealingly titled “Medical Paternalism Serves the Patient Best” states: “Central to medicine is the belief in beneficience: the Hippocratic Oath commits the practitioner to using his/her special knowledge and skills to benefit the patient; it entrusts and obligates the doctor to do what is in the best interest of the patient” (italics mine). It is often observed in writings on medical ethics that the Hippocratic Oath enjoins doctors to observe both the principles of nonmaleficience (that is, of doing no harm) and beneficience (of doing good). However, as James F. Childress writes in Who Should Decide? Paternalism in Health Care: “The categories of “harm” and “benefit” are not clinical. Some philosophers argue that most, if not all, of our language of health and disease is value-laden….clinical judgments…may presuppose values that are not articulated or defended and that would be opposed if stated” (45). An example of this lies in the general attitude toward death itself. Among physicians death is widely held to be an evil that must be avoided at all costs and under all circumstances. However there is what appears to be a growing opinion among the general populace that under certain circumstances (ie. prolonged and unrelenting pain and suffering) death may be preferable to life. To speak of death as “preferable” to life raises certain metaphysical questions (for example, “who” is there to “prefer” a “state” of nonexistence to one of existence?), but we will leave those aside for now and focus on practical considerations. Of primary importance is the question: Legally speaking, who gets to decide what is in a patient’s best interests? I use the word “patient” rather than “person” for a reason. The question of the limits of a person’s autonomy when they have voluntarily come under the care of a physician is quite distinct from a scenario in which this is not the case. In an effort to keep the focus of this paper narrow we will restrict ourselves to the former situation.
I have averred that an adult human must always be allowed final say as to whether or not they will accept lifesaving medical treatment and that they should even be permitted to request and doctors permitted to administer euthanasia, under certain special circumstances. Before exploring the repercussions of such a stance I will define these “special circumstances.” For what reasons might an adult human find what is sometimes called “physician-assisted suicide” desirable? I will take it as given that only a relatively small percentage of the human population at any given time is actively interested in shortening their own lives. While in the United States statistics related to attempted suicides are not systematically gathered, numbers regarding self-inflicted deaths are and they would seem to back up the position that suicide, while certainly a problem, is not any major threat to the general structure or stability of society (Kung, et al.). We may therefore conclude that suicide is usually seriously considered primarily by individuals in severe mental or physical distress. In circumstances in which qualified medical professionals determined that a patient’s physical or mental suffering were indeed curable and thus temporary in nature, it would obviously be in the patient’s best long-term interest to be denied the option of physician-assisted suicide. If however a number of physicians were to conclude independently that a patient’s suffering was terminal and that the level of suffering experienced was unlikely to lessen, a compassionate legal code would make euthanasia available as an option, absolving any physicians involved from prosecution. Naturally such legislation would require careful wording and the establishment of a well-ordered bureaucracy charged with oversight in order to ensure the proper employ of this last-resort measure.
Now let us consider a few situations and the repercussions within each of adopting my laissez-faire stance toward death. Each of these cases is factual.
Case 1: Mr. C, an athletic man in his late twenties, was severely burned in a natural gas explosion. When we was admitted to the hospital Mr. C had third degree burns over almost two-thirds of his body and told the staff that he did not want to be treated, only to be kept out of pain. The staff was in fact able to save Mr. C and he spent the next nine months in the hospital undergoing skin grafts, surgeries, painful daily washings, and dressing changes, all while persistently calling for his attending physicians to stop treatment, an action that he knew would mean certain death. The next year Mr. C. continually refused further corrective surgery on his hands and demanded to be allowed to go home to die. He cited the excruciation pain of his daily treatments, utter loss of independence, and recurring tortuous nightmares as his reasons for wanting to die. Mr. C. eventually pursued legal action in an effort to be released from the hospital (Childress).
While the full details of Mr. C’s long-term prognosis are not discussed in the text from which this case is lifted, it is noted that Mr. C had only a very slim chance of ever regaining much independence and that he had been blinded by the explosion, his fingers had been grafted together, and that his arms and legs were not fully functional. Could it really be said that the patient’s “best interests” were served by keeping him alive in such a painful and disfigured state against his wishes? Is society somehow served by such a course of action, one that seems to be clearly moralistic or even underwritten by a desire to avoid punitive legal measures? Surely not. True compassion and respect for individual liberty must compel us to acquiesce to an individual’s desire to end his or her own life in such a situation.
Case 2: Elizabeth Bouvia was a young woman suffering from cerebral palsy and pain who said that she was suicidal and was admitted to a general hospital’s psychiatric ward. Though she could not feed herself or swallow, Ms. Bouvia refused tube feeding. The attending psychiatrist strongly opposed this refusal by a patient who had been admitted expressly because of her suicidal condition (Sullivan and Youngner).
In a decision regarding Ms. Bouvia’s competence to decide whether or not to refuse treatment, the appellate court noted that she “merely resigned herself to accept an earlier death, if necessary, rather than live by feedings forced upon her,” and that “a desire to terminate one’s own life is probably the ultimate exercise of one’s right to privacy” (Sullivan and Youngner). I contend that a person’s judged mental competence has nothing to do with whether or not their wishes regarding medical treatment should be respected, with the possible exception of cases in which family is involved. If a mentally retarded or depressed person wishes to forego lifesaving medical treatment, what business is it of the state or the medical establishment to interfere? If close family was involved however it might be argued that they had a personal, vested interest in the continued existence of one judged mentally incompetent, but this would need to be argued legally. It would still be unclear whether this would indeed be in the patient’s best interests, and that, always, should be the final determining factor in such controversies. The next case speaks to just this sort of scenario.
Case 3: Maida Yetter was committed to Allentown State Hospital in the early nineteen-seventies and diagnosed with chronic, undifferentiated schizophrenia. During a routine physical exam the next year it was discovered that she had a breast discharge which indicated the possibility of breast cancer. When her doctor recommended a surgical biopsy Ms. Yetter refused, saying that “she was afraid because of the death of her aunt which followed such surgery.” When later questioned about her stance before a court, Ms. Yetter added that she was concerned that “the operation would interfere with her genital system, affecting her ability to have babies, and would prohibit a movie career.” Ms. Yetter was 60 years old (Veatch).
It is tempting in such a case to judge the individual incompetent to make their own life-or-death decisions, and this is just what Ms. Yetter’s brother did. He sued to be appointed her guardian, but was unsuccessful. In his decision, the judge stated:
It is clear that mere commitment to a state hospital for treatment of mental illness does not destroy a person’s competency or require the appointment of a guardian….If the person was competent while being presented with the decision and in making the decision which she did, the Court should not interfere even though her decision might be considered unwise, foolish or ridiculous (Veatch).
Case 4: In the early nineteen-nineties a 35-year-old Long Island woman who was one of Jehovah’s Witnesses hemorrhaged shortly after giving birth. The attending physicians believed that a blood transfusion was necessary to save the woman’s life, but she refused the procedure. Fifteen other Jehovah’s Witnesses, including the woman’s husband, circled her bed in an effort to prevent the transfusion, for which the hospital obtained a court order, but they were arrested and the transfusion was administered. The woman survived and went on to sue the hospital. She won the case.
This particularly case was so contentious because of the fact that the woman had just given birth. It was in fact the first to come before New York State’s highest court that involved a parent of a minor refusing lifesaving treatment. In the decision, Chief Judge Sol Wachtler wrote: “Although the state will not permit a parent to abandon a child, the state has never gone so far as to intervene in every personal decision a parent makes which may jeopardize the family unit or the parental relationship.” So it would seem that even the interests of those deeply affected by a person’s decision to end their own life by refusing medical treatment do not outweigh the individual’s right to do so. Of course this is undoubtedly an area in which the state has a clear and vested interest. If the woman had not been survived by a husband, who would have taken care of the child? The man as a single father may have qualified for some governmental assistance. Can taxpayers be expected to foot the bill for individuals who make seemingly reckless decisions regarding their own welfare? This matter is far from settled, and many states currently have statutes that hold a child’s right to a parent above a parent’s right to refuse medical treatment.
In an article published in The American Journal of Psychiatry, Mark D. Sullivan, M.D., Ph.D., and Stuart J. Youngner, M.D. observe:
Longstanding traditions in medicine and tort law have opposed treatment refusal that will result in the death of the patient. However, the past three decades have brought our nation to a medical, legal, and social consensus that under the right circumstances, all types of life-sustaining medical interventions may be withheld or withdrawn….The recognition of the right to die has taken place in the wake of advances in medical technology that make it possible to prolong life beyond the prospect of return to a satisfying and functional existence.
This “medical, legal, and social consensus” has yet to manifest itself fully. Reason, compassion, and a deep commitment to a pure definition of personal liberty would seem to dictate that it must. At the very least, the matter deserves a great deal more investigation and scrutiny.
Works Cited
Burnell, George M. Final Choices: To or To Die in an Age of Medical Technology. New
York: Insight Books-Plenum Press, 1993.
Childress, James F. Who Should Decide? Paternalism in Health Care. New York: Oxford
University Press, 1982.
Kung, Hsiang-Ching, Donna L. Hoyert, Jiquan Xu, and Sherry L. Murphy. “Deaths: Final
Data for 2005.” National Vital Statistics Report. 56.10 (24 April 2008): 1-121.
Lim, L. S. “Medical Paternalism Serves the Patient Best.” Singapore Medical Journal
43.3 (2002): 143-147.
Mill, John Stuart. On Liberty. 1859. Batoche Books – Kitchener, 2001.
Sullivan, Mark D. and Stuart J. Youngner. “Depression, Competence, and the Right to
Refuse Lifesaving Medical Treatment.” The American Journal of Psychiatry 151.7 (1994): 971.
Veatch, Robert M. Death, Dying, and the Biological Revolution: Our Last Quest for
Responsibility. Revised ed. New Haven: Yale University Press, 1989.
Verhovek, Sam Howe. “New York High Court Bars Forced Care to Save a Life.” The New York Times 19 January 1990.
