Biomedical Ethics

[mono]

I work full-time in critical care medicine, and, if I feel as passionate as and involved in anything like literature, writing, love, jogging and hiking, and baseball, I would call it the advanced applied science of health in order to basically help those in need; I would trade it for nothing.
I have wanted to start this thread ever since the death of Eluana Englaro (http://en.wikipedia.org/wiki/Eluana_Englaro) last February, a case dangerously near to that of Terri Schiavo (http://en.wikipedia.org/wiki/Terri_Schiavo), which incidentally occurred during my nursing school residence, starting all sorts of commotion in my graduation class among both professors and students, exacerbated by its wide media coverage. Unfortunately, due to the sensitive nature of the topic of biomedical ethics, I hesitated, and I hope I shall not regret lighting the first flame to what could easily turn into an emotional bonfire. With that in mind, especially after talking it over with a few moderators, I want to emphasize the clearly-printed Forum Rules (http://www.online-literature.com/forums/announcement.php?f=2354), especially those of "flaming, baiting, trolling, or ad hominem (personally attacking or insulting other members)," "maliciously hijacking discussion topics," and "threatening, harassing, abusing or intimidating other members." As an unwritten rule in medicine, I will not preach, nor even go as far to share, my own beliefs in biomedical ethics; I take them very seriously, and do everything I can to honor my patients' and thier loved ones' beliefs, even if I disagree with them, so long as they exist within the patient's best interest physiologically and psychologically (if applicable and attainable).
The applied science of medicine extends vast regions for promoting and advancing the health of individuals by multiple means, whether in absurdly segregated practices of Western and Eastern practices or wisely combined, from the holistic and systemic to the most specific perspective of one localized organ. The definition of what "helps," what "should help," and what "could help," however, seems greatly subjective and varies, such as in the cases of what seemed most beneficial for individuals like Eluana Englaro and Terri Schiavo, what some call the "Right-to-Die" argument and what others call euthanasia: see here (http://en.wikipedia.org/wiki/Right-to-die). For reasons like this, I cannot place more emphasis upon forming an advanced directive.
Biomedical ethics spans from these subjects of physician-assisted suicide, legalized here in Oregon (and most recently Washington state and Montana, too), to many others in addition: genetic engineering, stem-cell research, abortion, placebo, artificial insemination, contraception, circumcision (male and female), life extension, involuntary/unconsented fertilization, transexuality, blood/organ donation/transplantation, medical marijuana, feeding-tube placement, artificial-airway placement, resuscitation, lobotomy . . . the list continues. Humans have remained very much the same since the times of Hippocrates and Æsclepius, yet medical technology has come a long way, and many question not whether it has come too far, but whether medical science attempts to treat what ought not to receive treatment; regardless, contemporary medical professionals have the obligation of treating not only what appears treatable, but also what patients and their loved ones deem treatable. From controversies like these, the victimization of subjective beliefs, we get occurrences like the Dickey Amendment (http://en.wikipedia.org/wiki/Dickey_Amendment), the famous Roe vs. Wade (http://en.wikipedia.org/wiki/Roe_v_wade), the Terri Schiavo and Eluana Englaro cases (cited earlier), and Gonzales vs. Oregon (http://en.wikipedia.org/wiki/Gonzales_v._Oregon), and Gonzalez vs. Raich (http://en.wikipedia.org/wiki/Gonzales_v._Raich), among many other cases, whose debates never seem to fade, despite individuals elected by the majority of all making a ruling upon the subjects payed for by their taxes; allegedly, what seems legal and illegal never quite appear just or unjust.
Taking the "biomedical" part of biomedical ethics into consideration now, let us concentrate on the "ethics" part, and, for this, I will focus on a few different, but well-renowned, ethical philosophies of John Stuart Mill, Immanuel Kant, and Aristotle.
John Stuart Mill, a philosophical descendant of Jeremy Bentham, wrote Utilitarianism, a belief also known as consequentialism, an ethical philosophy that sought the greater good according to its results, the "by-all-means-necessary"-type philosophy, because all necessities, resources, and labor possible, if they result in the ideal outcome, carry their worth, or "utility," far enough that the risks and exertions rarely outweigh the positive outcomes and goals. Unlike most theory, especially in accordance to applying Mill's theory to biomedical ethics, this does not always have to adhere itself to pleasure, but only an attainment of happiness, as does Bentham's "Hedonic Calculus."
Immanuel Kant taught highly of universal, or deontological, ethics, in Groundwork for the Metaphysic of Morals, driven by categorical imperatives, or the concept of duty in its truest sense. Kant believed that, despite the end-product, which Mill's utilitarianism focused greatly upon, the intention of one's action, or sense of duty, mattered the greatest, subtracting all practical (attained) reason, hence leaving a decision-maker with his/her aims in order to make a just, sound rationale. He believed that many disparaties existed between human choice and values, and consideration of individual, indepedent, unique rights and abilities deserved respect, reverence, and heed.
Aristotle, in his Nicomachean Ethics, like Mill, sought the highest good, yet not for the purpose of its consequences, but for the good, in itself, seeming desirable for its own inherent sake with no premotivated further benefits. He focused on the middle between two limits, the Golden Mean, thereby balancing excess and deficiency; Aristotle took the pragmatic view that not everything appears within reach, but not everything seems impossible either - to save a life seems possible, for example, but only within human ability and virtue, and through this we obtain the highest good possible, a balance between the ideal and attainable.
In utilitarian/consequentialism, Kantian, and Aristotlean ethics, all seek benefit, which also seems a common theme in the survival of humans as a race, but I ask if certain benefits and abilities of contemporary medical science seek the greater good, seem worthy of universal ethics, or appear desirable within themselves. The travesties of Sophism can twist and turn the words of Mill, Kant, and Aristotle, just as common citizens can declare war for or against the U.S. Supreme Court, and all can make a lot of difference, for better or worse. What would Mill think of such things as physician-assisted suicide? What could Kant write for or against abortion? What would Aristotle's opinions claim for or against genetic engineering? Undoubtedly, we have all meditated upon the subjects, and learned individuals have studied the philosophers (and more, too), but what do you think?

[coberst]

Excellent subject for a thread!

Sooner or later we must face the fact of 'rational rationing of health care'.

“When you can measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot express it in numbers, your knowledge is of a meager and unsatisfactory kind; it may be the beginning of knowledge, but you have scarcely in your thoughts advanced to the state of science.”– Lord Kelvin

Lord Kelvin is making a value judgment. Has his value judgment advanced to the state of being a science? We do not have a physical standard for such a measurement so his judgment of this matter is unsatisfactory, at least in his valuation of judgment.

We have developed standards for quantifying certain physical parameters. We have standards for distance, weight, and time. The physical sciences utilize these standards for measuring things that have length, gravity, and duration. We have not developed similar quantifying standards for many other things that are of value to us. This may mean that the measurement of these values is unsatisfactory but again this is a value judgment, which is, as Lord Kelvin says, unsatisfactory. However unsatisfactory it does not mean that we cannot develop a disciplined, empirical, and systematic study of our values, that is to say we can develop a science of any domain of knowledge.

The quantification of qualities is useful especially in qualities that seldom change but, however unsatisfactory, it does not mean that we cannot develop a disciplined, empirical, and systematic study of our values.

Many of my teachers in grade school gave us report cards with number rather than letter grades. Since this is a quantification of value is it better than a letter grade? The quantification of an assessment of value seems to be an arbitrary assignment of the degree of value in which a judgment is held.

Can you quantify beauty, right, wrong, evil, good, sanity, aptness, inaptness, IQ (evidently we have developed a standard here), sophistication, democracy, freedom, etc?


Do you agree with Lord Kelvin that things that cannot be quantified can be known only unsatisfactory? Is quantification a necessary condition for the development of a systematic, disciplined, and empirical study of the matter?

The point of this OP is to focus upon the erroneous opinion that many people have as to the meaning of the word "science".

I think that in order to quantify one must have a fixed standard. We can quantify length because we have a standard for the measurement of length. That is why some think that science is restricted to those matters that can be measured. When we have a fixed standard we can make "absolute measurements". Some want to restrict the word "science" only to matters that provide an absolute measurement.


I think that it is easier to stick with a standard about things that have little or no meaning for us. Values are values because they are generally very meaningful. That is to say that we quantify matters that are less meaningful than those that are more meaningful. Sounds crazy, right? Lord Kelvin would say that we know a great deal more about the less meaningful.

[mono]

Thanks for contributing your insightful words, coberst - certainly worth a lot of consideration. :)

“When you can measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot express it in numbers, your knowledge is of a meager and unsatisfactory kind; it may be the beginning of knowledge, but you have scarcely in your thoughts advanced to the state of science.”– Lord Kelvin
. . .
We have developed standards for quantifying certain physical parameters. We have standards for distance, weight, and time. The physical sciences utilize these standards for measuring things that have length, gravity, and duration. We have not developed similar quantifying standards for many other things that are of value to us. This may mean that the measurement of these values is unsatisfactory but again this is a value judgment, which is, as Lord Kelvin says, unsatisfactory. However unsatisfactory it does not mean that we cannot develop a disciplined, empirical, and systematic study of our values, that is to say we can develop a science of any domain of knowledge.

The quantification of qualities is useful especially in qualities that seldom change but, however unsatisfactory, it does not mean that we cannot develop a disciplined, empirical, and systematic study of our values.

Do you agree with Lord Kelvin that things that cannot be quantified can be known only unsatisfactory? Is quantification a necessary condition for the development of a systematic, disciplined, and empirical study of the matter?
The physical and natural sciences, which a physicist like Lord Kelvin undoubtedly mastered as well as founded fundamental rules, indeed, relies not greatly but entirely upon specific, measurable, empirical proof to fulfill its purpose to search for truth; hence, as you mentioned, we have multiple units of measurement for distance, weight, time, and Lord Kelvin even developed his own for temperature. We even have sciences within sciences, biology itself splitting into the studies of target species, microorganisms, specific bodily organs, etc.; in order to postulate a theory in science seems a science in itself, the scientific method, suspiciously close to the Socratic method of B.C.E. times.
In the natural sciences of biology, chemistry, physics, ecology, astronomy, and all of their branches, everything exists within measurements, and what does not seem within the realm of human knowledge and perception, such as the theory of the expanding universe, exists as theories. In applying what we know, specifically of human biology and organic chemistry, medicine operates according to the scientific methods to benefit health, all within measurable, specific, empirical efforts, as Lord Kelvin would think ideal, and as appears most suitable for the benefit of worldwide health. Unfortunately, certain branches of philosophy cannot operate the same, ethics as one of them. Jeremy Bentham, in the early days of pre-Mill utilitarianism, attempted to form "hedonic calculus," which specifically, empirically, and systemically calculated the justice of an action by measurable units; this exists more within the classroom of moral philosophy 101 now, having undergone enough criticism, especially by Robert Nozick and his theory of the "utility monster." Deeming what appears most beneficial and healthy for individuals as a whole, regardless of intelligence, background, religion/spirituality, preexisting conditions, risks, from a medical or lawful perspective, seems difficult not only to discover, but even more challenging to measure for scientific purposes. Instead, in cases like ones facing biomedical ethics, medical science functions on a good/bad, yes/no, positive/negative-like basis; even more unfortunate, many actions in medical science cannot get undone - the alleged "soul" inside the drop of blood of a Jehovah's Witness cannot get localized from the other multiple liters of getting pumped around his/her body.
Unlike the concrete consistency of science and mathematics, the abstract and persistent ingredients of ethics, values, and beliefs cannot fit under the electron microscope for quantitative analysis. The lewd, but true, statement goes: "opinions are like arseholes, everyone has one," and a pro-birth-control woman has just as much of a female reproductive system as an anti-birth-control/abstinent woman, just as well that a conservative politician has 22 chromosomes available for genetic manipulation and engineering as well as a socialist politician (though I feel quite sure that some politicians bear an extra 21st chromosome) - these, at least, appear measurable, as opposed to the opinions and beliefs beneath their dura and pia maters.
The subjectivity of individual ethics, from a person-to-person to a people-to-people basis, thus forces medical science to function on a good/bad protocol, explaining why I bring into the discussion something as abstract and unscientific as ethical/moral philosophy, plaguing both patients and their medical professionals.
Did Englaro and Schiavo have the right to die in their vegetative states, and, furthermore, should their families have the rights to decide that for them, considering neither had an official advanced directive?
Does involuntary/unconsented sterilization of the mentally challenged sound too close to eugenics?
Should a man have the option to surgically and hormonally become a woman, or vice versa?
Did Norma McCorvey (a.k.a. "Jane Roe") have the right to abort her fetus? What about in cases of rape or incest?
Should a terminally ill patient, judged of sound mind by a psychologist, have the ability to ask for/take a fatal physician-prescribed dose of phenobarbital to alleviate his/her suffering?
If a patient finds that marijuana, as an inhalant, treats best the harsh side-effects of chemotherapy for cancer, the abdominal discomfort of Crohn's disease and ulcerative colitis, the involuntary spasms of multiple sclerosis, Parkinson's disease, and spinal cord injuries, should s/he have the option to use it lawfully?

[coberst]

We will soon be forced to face the reality that we must ration health care not based upon the wealth of the individual, as is now the policy, but based upon the fact that we can no longer ignore the long range implications of our decisions.

[Madame X]

Did Englaro and Schiavo have the right to die in their vegetative states, and, furthermore, should their families have the rights to decide that for them, considering neither had an official advanced directive? ...
Should a terminally ill patient, judged of sound mind by a psychologist, have the ability to ask for/take a fatal physician-prescribed dose of phenobarbital to alleviate his/her suffering?

If you'll allow an apropos comparison on these points: when an animal, (say, granny's pet poodle) becomes old and infirm, or is otherwise suffering from illness or disease with little hope of recovery or, for that matter, decent quality of life, you'll notice how people are a bit less scrupulous -that is, from an ethical standpoint-, about putting their precious pets down as these people, in their alleged sensitivity to the animal's suffering, are quite firm in believing it to be the "humane" thing to do. In many cases, I'd agree. However, I find it funny that many of these sympathetic folk prove to be equally as firm in resisting, if not outright condemning the apparently no longer "humane" methods of treatment when similar strife affects the human constitution. A rare instance in which animal rights actually seems to be ahead of the game, I think. :nod:

[mono]

If you'll allow an apropos comparison on these points: when an animal, (say, granny's pet poodle) becomes old and infirm, or is otherwise suffering from illness or disease with little hope of recovery or, for that matter, decent quality of life, you'll notice how people are a bit less scrupulous -that is, from an ethical standpoint-, about putting their precious pets down as these people, in their alleged sensitivity to the animal's suffering, are quite firm in believing it to be the "humane" thing to do. In many cases, I'd agree. However, I find it funny that many of these sympathetic folk prove to be equally as firm in resisting, if not outright condemning the apparently no longer "humane" methods of treatment when similar strife affects the human constitution. A rare instance in which animal rights actually seems to be ahead of the game, I think. :nod:
Indeed, it seems much easier to "advocate" for a beloved pet than it apparently seems to advocate for a spouse, parent, sibling, child, grandparent, or companion who speaks, rather than meows, barks, or chirps. Coberst, in quoting Lord Kelvin, did very well at describing the many disparaties between objective measurements and the abstract consistency of ethics and sentiment; when a doctor tells a patient s/he has a terminal illness, giving them an estimated 6 or less months to live, an individual has a choice to resist or submit to declining health, as does his/her family, but when a veteranarian tells a pet's owner that the pet has a terminal illness, it almost seems we assume that the veteranarian "speaks" the language of the pet, knows its suffering, thereby seeming to give a more objective judgment of that dichotomy between a pet able to heal and a terminal one. People suffer and pets suffer, and when they cannot heal, it seems in the best interest to maximize what remains.
If granny went through the entire process of utilitarian, deontological, and Nichomachean ethics, in her distressed state, to deem that it seemed best to euthanize her pet poodle, let us say, afflicted with cancer, it certainly makes one wonder if she would reach a similar decision if her husband also developed cancer, metastasizing to his brain, thereby affecting his cognition, and she had to advocate for him. Very good point, Madame X. ;)

[Helga]

If you'll allow an apropos comparison on these points: when an animal, (say, granny's pet poodle) becomes old and infirm, or is otherwise suffering from illness or disease with little hope of recovery or, for that matter, decent quality of life, you'll notice how people are a bit less scrupulous -that is, from an ethical standpoint-, about putting their precious pets down as these people, in their alleged sensitivity to the animal's suffering, are quite firm in believing it to be the "humane" thing to do. In many cases, I'd agree. However, I find it funny that many of these sympathetic folk prove to be equally as firm in resisting, if not outright condemning the apparently no longer "humane" methods of treatment when similar strife affects the human constitution. A rare instance in which animal rights actually seems to be ahead of the game, I think. :nod:

I don't think I can say much on this topic even though I think about this a lot, but I definetly agree with you.
in my opinion it has always been a privilege the animals have above us to be able to just go to sleep when they are old and/or have a life threatening illness. I work at a home for the elderly and you can see it in some peoples eyes how tired they are and just want to leave this world, but their kids refuse to let them go and insist everything is done to keep them alive even though their mind and soul and often their body is gone or just barely holding on. my great grandmother reached the age of 105 years and for about 10 or 15 years she said the God forgot her. her husband and friends were gone even some of her children but she was still here.

[RichardHresko]

There are two factors that make it easier to deal with the situation of pets than with people: consciousness and the fact humans are social animals. The former complicates the question of relieving suffering since for an animal (as far as we know at this stage) there is no awareness of a future or a unique self that becomes dead to this world and thus the relief of present suffering is the chief issue. Secondly, the fact that people are not islands, to use Donne's image, presents problems as well. This comes up in cases like Schiavo's where there is no unambiguous indication of consciousness.

There is perhaps a value to the tension caused by these elements -- the constant need to reflect on what it means to be human. Somehow it would seem to lessen what we are if one could facilely decide when it is time for "lights out" for people.

[JWHooper]

There are two factors that make it easier to deal with the situation of pets than with people: consciousness and the fact humans are social animals. The former complicates the question of relieving suffering since for an animal (as far as we know at this stage) there is no awareness of a future or a unique self that becomes dead to this world and thus the relief of present suffering is the chief issue. Secondly, the fact that people are not islands, to use Donne's image, presents problems as well. This comes up in cases like Schiavo's where there is no unambiguous indication of consciousness.

There is perhaps a value to the tension caused by these elements -- the constant need to reflect on what it means to be human. Somehow it would seem to lessen what we are if one could facilely decide when it is time for "lights out" for people.
We are not social animals, unless if we can talk Shakespearean language.

'Upon the earth's increase why shouldst thou feed,
Unless the earth with thy increase be fed?
By law of nature thou art bound to breed,
That thine may live when thou thyself art dead;
And so, in spite of death, thou dost survive,
In that thy likeness still is left alive.'

By this the love-sick queen began to sweat,
For where they lay the shadow had forsook them,
And Titan, tired in the mid-day heat,
With burning eye did hotly overlook them;
Wishing Adonis had his team to guide,
So he were like him and by Venus' side.

And now Adonis, with a lazy spright,
And with a heavy, dark, disliking eye,
His louring brows o'erwhelming his fair sight,
Like misty vapours when they blot the sky,
Souring his cheeks cries 'Fie, no more of love!
The sun doth burn my face: I must remove.'

'Ay me,' quoth Venus, 'young, and so unkind?
What bare excuses makest thou to be gone!
I'll sigh celestial breath, whose gentle wind
Shall cool the heat of this descending sun:
I'll make a shadow for thee of my hairs;
If they burn too, I'll quench them with my tears.

'The sun that shines from heaven shines but warm,
And, lo, I lie between that sun and thee:
The heat I have from thence doth little harm,
Thine eye darts forth the fire that burneth me;
And were I not immortal, life were done
Between this heavenly and earthly sun.

'Art thou obdurate, flinty, hard as steel,
Nay, more than flint, for stone at rain relenteth?
Art thou a woman's son, and canst not feel
What 'tis to love? how want of love tormenteth?
O, had thy mother borne so hard a mind,
She had not brought forth thee, but died unkind.


WE CAN COMPARE love with ethical issues with philosophical arguments. This part tells us that once Venus is our planet, then that planet will obey the laws of nature of literature of infinity.

[Madame X]

Somehow it would seem to lessen what we are if one could facilely decide when it is time for "lights out" for people.

Weeeell, we’re not exactly talking about sending grandpa to the gas chamber over a hangnail here. ;) Look at it in context: if someone is suffering his way to certain death anyway (and I certainly mean at an exponentially greater rate in terms of pain and pace than the rest of us), why prolong the process? I don’t presume to claim it’s an easy decision to make, but I don’t see how idly watching the painful and irrevocable deterioration of a loved one is any preferable.

[RichardHresko]

Weeeell, we’re not exactly talking about sending grandpa to the gas chamber over a hangnail here. ;) Look at it in context: if someone is suffering his way to certain death anyway (and I certainly mean at an exponentially greater rate in terms of pain and pace than the rest of us), why prolong the process? I don’t presume to claim it’s an easy decision to make, but I don’t see how idly watching the painful and irrevocable deterioration of a loved one is any preferable.

Of course there is the question here of the value of suffering as well. There seems an unspoken assumption in many circles that suffering is necessarily an evil and should be avoided. This is not to advocate a rush to suffer, but a caution that there may be more at stake than pain management.

[mono]

Interspecies euthanasia seems to have ended up as a hot topic on the thread - great!
I agree, RichardHresko, that most do not keep social animals as pets; many have cats, dogs, birds, fish, or maybe a reptile, amphibian, or rodent, at the most unique, and several individuals find the situation most just in their pets not to prolong the suffering of a chronic or acute illness/injury in their loved pets via euthanasia - often times, a veteranarian in consultation with the owner(s), judges best when there seems no hope of recovery nor alleviation of suffering, not only physical, but when a pet loses such abilities as feeding and hygeine. Some animal activists and people of certain faiths have the idea that euthanasia of a pet seems immoral, and that we assume what seems in the best interest of a pet, taking advantage that the pet cannot advocate for itself.
Terri Schiavo had not only lost her ability at cognition, but nearly all of her bodily functions with an established severe case of hydrocephalus, her intracranial ventricles had expanded greatly, depleting almost all of the useful tissue of not only her cerebral cortex, but her whole brain; not only had she lost many human faculties necessary to live a common life (walking, talking, eating - one could ask if she could even judge whether she felt hungry or sleepy), but she had lost her self-advocacy, seeming not even to understand language any longer.
Comparing her case, or Eluana Englaro's, with a household cat with established terminal cancer, seems in some ways a difficult one, in others easy, particularly in terms of judging the interpretation of suffering; unless the cat proceeded into a vegetative, comatose state, it may possibly still perceive the pangs of suffering - pain, hunger, thirst, etc., while Schiavo and Englaro appeared to have lost even those faculties, as well as their self-advocacies. Does this seem to have justified their deaths via euthanasia? Some seem to think so, others not (like former President George W. Bush or Italian PM Silvio Berlusconi); my opinion does not matter, nor does it make a difference.
Good topic! ;)

Somewhat along the same lines, in an individual who has not lost his/her ability of self-advocacy, unlike Schiavo or Englaro, has a terminal illness, and cannot withstand the suffering (physical, psychological, and/or spiritual), should s/he have the right to another form of euthanasia, called physician-assisted suicide?

[mono]

By the way, interesting that the subject should come up, as so recently the BBC reports of the MS woman wins right-to-die fight (http://news.bbc.co.uk/2/hi/health/8176713.stm) just yesterday in Switzerland, a topic making worldwide headlines.

[RichardHresko]

Interspecies euthanasia seems to have ended up as a hot topic on the thread - great!
I agree, RichardHresko, that most do not keep social animals as pets; many have cats, dogs, birds, fish, or maybe a reptile, amphibian, or rodent, at the most unique, and several individuals find the situation most just in their pets not to prolong the suffering of a chronic or acute illness/injury in their loved pets via euthanasia - often times, a veteranarian in consultation with the owner(s), judges best when there seems no hope of recovery nor alleviation of suffering, not only physical, but when a pet loses such abilities as feeding and hygeine. Some animal activists and people of certain faiths have the idea that euthanasia of a pet seems immoral, and that we assume what seems in the best interest of a pet, taking advantage that the pet cannot advocate for itself.
Terri Schiavo had not only lost her ability at cognition, but nearly all of her bodily functions with an established severe case of hydrocephalus, her intracranial ventricles had expanded greatly, depleting almost all of the useful tissue of not only her cerebral cortex, but her whole brain; not only had she lost many human faculties necessary to live a common life (walking, talking, eating - one could ask if she could even judge whether she felt hungry or sleepy), but she had lost her self-advocacy, seeming not even to understand language any longer.
Comparing her case, or Eluana Englaro's, with a household cat with established terminal cancer, seems in some ways a difficult one, in others easy, particularly in terms of judging the interpretation of suffering; unless the cat proceeded into a vegetative, comatose state, it may possibly still perceive the pangs of suffering - pain, hunger, thirst, etc., while Schiavo and Englaro appeared to have lost even those faculties, as well as their self-advocacies. Does this seem to have justified their deaths via euthanasia? Some seem to think so, others not (like former President George W. Bush or Italian PM Silvio Berlusconi); my opinion does not matter, nor does it make a difference.
Good topic! ;)

Somewhat along the same lines, in an individual who has not lost his/her ability of self-advocacy, unlike Schiavo or Englaro, has a terminal illness, and cannot withstand the suffering (physical, psychological, and/or spiritual), should s/he have the right to another form of euthanasia, called physician-assisted suicide?

Very well reasoned. An issue that I did not address and you bring to the fore, is whether there is a right to self-termination, and if so, to what extent can that person delegate such rights.

I believe that it is reasonably clear that as a moral agent a person has a right to act in any way that does not have as its intent malicious interference with the rights of others. I also believe that others have a moral responsibility to prevent others from doing harm to themselves or other people.

What this means in the current discussion is that one desiring self-termination has a moral right to do so, but must be prepared to demonstrate that the decision is one that is being done for a 'good' -- the relief of pain that has become unbearable, for example, and that the death, as it were, were incidental to achieving that good.

I think, given the nature of the decision, that anything short of a positive determination that self-termination a) was the person's wish, and b) was clearly consistent with the moral good mentioned in the preceding paragraph, would have to be rejected as grounds for assistance.

[Nick Capozzoli]

As a neurologist, I was especially interested in the public discussions if the Terry Schiavo case. Since I never examined her and have only the press reports to go on, my opinion has little weight. But I have cared for many patients who have suffered hypoxic brain injury, including patients who were in coma and "persistent vegetative state." I've even had a couple of patients who were in that fortunately rare but really awful "locked in state," depicted in The Count of Monte Cristo and a fairly recent movie about a soldier badly shot up in WWI.

The main problem of the Sciavo case, as I see it, is that there were competing "expert" opinions about her neurological state. Was she "vegetative" or did she have any "consciousness." Frankly, I don't know. Some doctors who saw her felt she was aware, and others did not. Unfortunately, the case was highly politicized, and those who argued one way or the other seemed to have political agenda.

One thing that caught my attention, as a neurologist, was the publication of CT images of Ms. Sciavo's brain in the press. She did suffer anoxic injury to her brain, and this was evident of the widely published CT images, which showed a great deal of loss of cerebral tissue, clearly evident as "abnormal" to anyone when compared to a "normal" brain CT, which was conveniently provided by the newspapers that published these photos.

The problem is that I have seen the CT images of the brains of many patients which look just as "terrible" as Ms. Schiavo's...e.g. the brains of some of my patients with hydrocephalus. A few of these were the brains of folks who were quite cognitively intact. One of my patients was scanned because he had headaches, and was incidentally discovered to have had congenital hydrocephalus, with a CT that showed huge fluid filled ventricles and a mere
1cm thick cerebral cortex that was literally flattened against his skull. He was an electrical engineer, but if you didn't know that you would perhaps have assumed that he was a low grade imbicile if not vegetative. Please excuse my use of the old clinical term, "imbicile."

[mono]

Very well reasoned. An issue that I did not address and you bring to the fore, is whether there is a right to self-termination, and if so, to what extent can that person delegate such rights.

I believe that it is reasonably clear that as a moral agent a person has a right to act in any way that does not have as its intent malicious interference with the rights of others. I also believe that others have a moral responsibility to prevent others from doing harm to themselves or other people.

What this means in the current discussion is that one desiring self-termination has a moral right to do so, but must be prepared to demonstrate that the decision is one that is being done for a 'good' -- the relief of pain that has become unbearable, for example, and that the death, as it were, were incidental to achieving that good.

I think, given the nature of the decision, that anything short of a positive determination that self-termination a) was the person's wish, and b) was clearly consistent with the moral good mentioned in the preceding paragraph, would have to be rejected as grounds for assistance.
A fine explanation, RichardHresko, and it sounds as though you take a very utilitarian stance upon the subject, seeking a result that will bring about the greater good of all, as described in my initial post in explaining Mill and Bentham (though I feel a bit more versed in the former). Taking one's own life seems a difficult decision in itself, whether an individual has a terminal illness or not, and receiving the unfortunate news from a medical professional of a terminal illness, I would not doubt, feels even more difficult to hear; the former seems to overwhelm one with the control of self-destruction, the latter from a lack of control - in reading/hearing statements from patients approved for physician-assisted suicide, the option gave them a medium between the two extremes of control, and its lack thereof, plus did not further maximize the discontenting thought of their impending doom, regardless, from a terminal affliction. From a utilitarian perspective, and according to their subjective beliefs, they sought the option in desiring the greater good.
While not wanting to call it wrong or right from my perspective, I feel that the opposition to PAS does not quite assume the modesty of your utilitarian place of stand, bluntly calling it objectively wrong. From this way, a reader can easily twist the deontological ethics of Kant, also mentioned in my first post, of acting according to duty and intention. Does it seem wisest, and within the patient's and medical professionals' duties and best motives, to fight a disease/disorder without end, even if considered terminal? Or does it appear within the duty and best intention of the medical professional, such as a physician, to notify the patient and/or his/her loved ones when a disease/disorder has reached a terminal stage and there exists little to no chance of survival, then to assist to comfort? At what point do we give up, at what point do we keep fighting? Where does Aristotle's "Golden Mean" fit between the balances of excess (aggressive treatment of a terminal disease/disorder, suffering) and deficiency ("accepting fate," relief, comfort)?

As a neurologist, I was especially interested in the public discussions if the Terry Schiavo case. Since I never examined her and have only the press reports to go on, my opinion has little weight. But I have cared for many patients who have suffered hypoxic brain injury, including patients who were in coma and "persistent vegetative state." I've even had a couple of patients who were in that fortunately rare but really awful "locked in state," depicted in The Count of Monte Cristo and a fairly recent movie about a soldier badly shot up in WWI.

The main problem of the Sciavo case, as I see it, is that there were competing "expert" opinions about her neurological state. Was she "vegetative" or did she have any "consciousness." Frankly, I don't know. Some doctors who saw her felt she was aware, and others did not. Unfortunately, the case was highly politicized, and those who argued one way or the other seemed to have political agenda.

One thing that caught my attention, as a neurologist, was the publication of CT images of Ms. Sciavo's brain in the press. She did suffer anoxic injury to her brain, and this was evident of the widely published CT images, which showed a great deal of loss of cerebral tissue, clearly evident as "abnormal" to anyone when compared to a "normal" brain CT, which was conveniently provided by the newspapers that published these photos.
Wonderful to have another medical professional on the forum - I had no idea - a neurologist! Terri Schiavo's case occurred while I attended nursing school, and, always having had an interest in neurology (I work in a general ICU, but personally attend primarily to neurology, neurosurgery, and endocrinology), I gained a sharp interest, as well, also considering my interest in ethics. Of course, I never stepped in the presence of Schiavo, let alone examined her either, and I feel quite positive, doc, that you feel more confident in your head CT scan-reading skills than I do; regardless, the anoxic brain injury following her unwitnessed cardiopulmonary arrest (related to hypokalemia), as well as her subsequent hydrocephalus, seemed apparent, if not obvious, making one wonder if she owned much activity superior to the diencephalon, especially since she required a thalamic stimulator. True, she received many "evaluations" from "professionals" (even her husband worked as a respiratory therapist), as you nobly mentioned, but along with what I think you may have intended, we can say a lot about confirmatory biases during such "evaluations;" as you have, too, no doubt, I have heard of "professionals" interpreting decorticate and decerbrate posturing as voluntary pronation and supination. Such confirmatory biases, I fear, could have contributed to the multiple-years-long debate whether to withdraw treatment or prolong her majority-determined persistent vegetative state.

The problem is that I have seen the CT images of the brains of many patients which look just as "terrible" as Ms. Schiavo's...e.g. the brains of some of my patients with hydrocephalus. A few of these were the brains of folks who were quite cognitively intact. One of my patients was scanned because he had headaches, and was incidentally discovered to have had congenital hydrocephalus, with a CT that showed huge fluid filled ventricles and a mere
1cm thick cerebral cortex that was literally flattened against his skull. He was an electrical engineer, but if you didn't know that you would perhaps have assumed that he was a low grade imbicile if not vegetative. Please excuse my use of the old clinical term, "imbicile."
:eek2: Wow! Amazing how the body has such an ability to adapt, eh?

[RichardHresko]

A fine explanation, RichardHresko, and it sounds as though you take a very utilitarian stance upon the subject, seeking a result that will bring about the greater good of all, as described in my initial post in explaining Mill and Bentham (though I feel a bit more versed in the former). Taking one's own life seems a difficult decision in itself, whether an individual has a terminal illness or not, and receiving the unfortunate news from a medical professional of a terminal illness, I would not doubt, feels even more difficult to hear; the former seems to overwhelm one with the control of self-destruction, the latter from a lack of control - in reading/hearing statements from patients approved for physician-assisted suicide, the option gave them a medium between the two extremes of control, and its lack thereof, plus did not further maximize the discontenting thought of their impending doom, regardless, from a terminal affliction. From a utilitarian perspective, and according to their subjective beliefs, they sought the option in desiring the greater good.
While not wanting to call it wrong or right from my perspective, I feel that the opposition to PAS does not quite assume the modesty of your utilitarian place of stand, bluntly calling it objectively wrong. From this way, a reader can easily twist the deontological ethics of Kant, also mentioned in my first post, of acting according to duty and intention. Does it seem wisest, and within the patient's and medical professionals' duties and best motives, to fight a disease/disorder without end, even if considered terminal? Or does it appear within the duty and best intention of the medical professional, such as a physician, to notify the patient and/or his/her loved ones when a disease/disorder has reached a terminal stage and there exists little to no chance of survival, then to assist to comfort? At what point do we give up, at what point do we keep fighting? Where does Aristotle's "Golden Mean" fit between the balances of excess (aggressive treatment of a terminal disease/disorder, suffering) and deficiency ("accepting fate," relief, comfort)?

Wonderful to have another medical professional on the forum - I had no idea - a neurologist! Terri Schiavo's case occurred while I attended nursing school, and, always having had an interest in neurology (I work in a general ICU, but personally attend primarily to neurology, neurosurgery, and endocrinology), I gained a sharp interest, as well, also considering my interest in ethics. Of course, I never stepped in the presence of Schiavo, let alone examined her either, and I feel quite positive, doc, that you feel more confident in your head CT scan-reading skills than I do; regardless, the anoxic brain injury following her unwitnessed cardiopulmonary arrest (related to hypokalemia), as well as her subsequent hydrocephalus, seemed apparent, if not obvious, making one wonder if she owned much activity superior to the diencephalon, especially since she required a thalamic stimulator. True, she received many "evaluations" from "professionals" (even her husband worked as a respiratory therapist), as you nobly mentioned, but along with what I think you may have intended, we can say a lot about confirmatory biases during such "evaluations;" as you have, too, no doubt, I have heard of "professionals" interpreting decorticate and decerbrate posturing as voluntary pronation and supination. Such confirmatory biases, I fear, could have contributed to the multiple-years-long debate whether to withdraw treatment or prolong her majority-determined persistent vegetative state.

:eek2: Wow! Amazing how the body has such an ability to adapt, eh?

I am also extremely impressed (though, I will add, humbled as well) by the quality of responses here. A good deal of my experience in these matters is second-hand, and should be valued accordingly.

I suppose that my modest utilitarianism here is due to my accepting that others may legitimately have other concerns than the somewhat crude moral calculus of Jeremy Bentham. I think it is possible for someone to opt to accept suffering for reasons that are not masochistic. See for example, the case of Flannery O'Connor.

I am much in the mind of Mill in the sense that he realized that a truly healthy society was one that had a wide tolerance for ideas and POVs that were tolerant of others.

One position that the Roman Catholic Church accepts is that things that are done to bring comfort, even if the side effect may be death, is allowable as long as death itself is not the primary intent. Thus, for example, abortion is allowable if it is an unavoidable consequence of saving a mother's life, and administering morphine to relieve unbearable pain is permissible even if the depression of breathing will hasten death. While one can argue about the details, what I find admirable is a careful balancing of relief of suffering and valuation of human life.

The only additional caveat that I would add to the discussion of PAS is that cost should not be used as a factor. That is a slippery slope we should avoid. While utilitarians may argue C/B ratios there is a certain point that a line needs to be drawn in terms of human life if we are not to reduce human experience to a calculation.

[Nick Capozzoli]

Mono,

Thanks for your response to my post on TS.

I mentioned the widely published CT images of TS's brain, because I think they were published just because they looked "terrible," and therefore supported the notion that TS was "brain dead," and made it easier for those who read the newspaper articles to accept the idea that TS was not sentient and for all practical purposes "dead," so as to make it acceptable to withdraw food and water until her body died.

I want to say that I have no idea whether or not TS was conscious, because I never examined her. If I had, I would be able to render a professional opinion. But I can say that she was not "brain dead." Brain death is a specific diagnosis, and easily determined by clinical criteria that assess brainstem function (cardiopulmonary function, eye movements and pupillary reactions, etc. TS clearly was not "brain dead" by these criteria. The question is whether or not she had any awareness, or "higher cortical function." This, from all that I have read on the internet and the press, iis open to debate.

What I can say is that I believe the CT scans of her brain didn't prove that she was capable or incapable of consciousness. My point was that I've seen just as "horrible looking" brains scans of sentient and cognitively functional patients. It's really amazing how hardy the human brain is. As I said, I've seen apparently functional patients (mainly hydrocephalics) whose CT/MRI
scans reveal a cranium that is mostly filled with fluid with an outrageously thinned out rind of cerebral cortex.

Nick