A right to anaesthesia, a right to physician euthanasia?

In an editorial in Anaesthesia Julian Savulescu and Janet Radcliffe‐Richards suggest that many people who are against the deliberate killing of terminally ill patients who wish to die should have no objection to what is known as terminal sedation, bringing about unconsciousness for terminally ill patients until their natural death, see Anaesthesia . I agree with Savulescu and Radcliffe‐Richards that most people would accept that sedation for terminally ill patients is not wrong when death is imminent. In France in 2016 a law came into effect granting terminally ill patients the right to anaesthesia until death. Sinmyee et al go further and argue that a right to anaesthesia should be available to all patients who choose to end their life by starvation or dehydration, see Sinmyee . Would most people accept that sedation for terminally ill patients is not wrong when death is inevitable but not imminent? Perhaps a patient has a prognosis that he has only six months to live. Secondly would most people accept that sedation for terminally ill patients is not wrong when used to relieve suffering which they cause themselves by a refusal to eat or to drink? I’m not sure what most people would find acceptable in either of these scenarios. In this posting I will firstly briefly summarise the argument why it isn’t morally wrong to sedate terminally ill patients even if their current suffering is due caused by a refusal to eat or drink. I will then consider what implications accepting this argument has for accepting physician assisted suicide and voluntary euthanasia.

Let us accept that any competent person has right to refuse to take food and water. It might be objected that in some cases the person in question is unlikely to be competent due to eating disorders such as anorexia. However clearly this objection doesn’t carry much weight when considering terminally ill patients. Let us also accept that relieving pain is a legitimate end of medicine even when this lessens a patient’s life span. Let us still further accept that relieving pain remains a legitimate end of medicine even when this pain is due to self-harm. We treat drug users for their addiction. Lastly let us accept that if pain cannot be controlled by any other means that it can be controlled by deep sedation. It appears to follow that deeply sedating a patient suffering from a terminal illness, even if his immediate suffering is caused by his refusal to eat or drink, is a legitimate end of medicine. It follows that in these circumstances deep sedation would not be morally wrong.

Let us now consider how permanent deep sedation differs from death. For a dead person conscious life is over. Conscious life is also over anyone who will be deeply sedated until he dies. Of course for someone who is deeply sedated some important unconscious physiological processes such as breathing will continue. The same is not true of the dead. But do these unconscious physiological processes matter if someone will never resume consciousness or take part in life again? If they do matter who do they matter to? These unconscious physiological processes certainly don’t matter to the sedated person. If they doesn’t matter to the person involved why should they matter morally to others? It would appear to follow that there is no significant moral difference between being dead and being deeply sedated until death. If this is so is there any moral difference between a doctor deeply sedating someone until he dies and helping him die a good death if he requests help to do so? If dying and being deeply sedated until death are equivalent for moral concerns then we should be prepared to conclude that if we are prepared to accept deep sedation until death that we should be prepared to accept physician assisted suicide PAS.

It might be objected that deep sedation involves no suffering whilst helping a patient to die might do so. However even if we accept this objection the above question might be reframed. Is there any moral difference between a doctor deeply sedating someone until he dies and deeply sedating someone prior to carry out his previously expressed wishes for voluntary euthanasia? If there isn’t any difference then we should be prepared to conclude that if we are prepared to accept deep sedation until death that we should be prepared to accept voluntary euthanasia, which might require prior sedation, when requested by a terminally ill patient.

I now want to examine two major objections to the above conclusion. Firstly it might be objected that the above argument depends on the concept of a person and that when considering deep sedation and voluntary euthanasia we should consider human beings instead. My objector might argue that that matters is not whether a person continues to exist bur whether a human being continues to exist. What does it mean for a human being to continue existing? Is someone who will never regain consciousness but for whom unconscious physiological processes such as breathing continue still a human being? My objector might conclude the answer is obvious and is affirmative. However if we consider the concept of brain death commonly used in transplant medicine the answer is not obvious. Someone is brain dead if he has a permanent absence of cerebral and brainstem functions, however mechanical ventilators and other advanced critical care services can maintain unconscious physiological processes such as breathing for some time. Whether someone who is brain dead remains a human being is far from obvious for we can use his organs for transplant subject to consent. Why does brain death matter? It matters not simply because of a loss of cerebral and brainstem functions but because the implications of these losses. These losses lead to a permanent loss of consciousness. If the above is accepted then substituting human for persons doesn’t affect my original argument.

I now want to consider a second objection to my argument that if we are prepared to accept deep sedation of the terminally ill patients until death that we should also be prepared to voluntary euthanasia for such patients. It might be objected that I have slipped too easily from considering PAS to considering voluntary euthanasia and that the two aren’t equivalent. PAS is self-administered whilst voluntary euthanasia is carried out by a physician. I made this move because it has been suggested that PAS might involve suffering by the terminally ill patient. As a philosopher I am unable to say much about whether PAS might involve suffering. However I can say something about the possible scenarios. Firstly if PAS doesn’t necessarily involve suffering then my original conclusion stands. Next let us assume that PAS involves some limited suffering. In this scenario it might be questioned whether a terminally ill patient needs to be fully anaesthetised for PAS to take place? Perhaps a patient’s pain might be alleviated without affecting his cognitive abilities allowing him to carry out PAS. Once again my original conclusion stands. Lastly let us assume that PAS involves suffering that cannot be fully alleviated without full anaesthesia. In this scenario PAS isn’t possible with full pain relief. In this scenario the question changes and becomes, if we are prepared to accept deep sedation until death then why shouldn’t we be prepared to accept voluntary euthanasia?

In order to answer the above question I want to consider two further scenarios. In both scenarios I will assume the patient is fully competent. In the first I will assume that the patient is capable of initiating the start of his anaesthesia before his physician takes over and delivers a fatal dose. In this scenario why is the patient initiating his own anaesthesia? I would suggest he isn’t only initiating a form of pain relief. He is only initiating pain relief in order to die. In this scenario the patient’s actions resemble those of a patient undergoing PAS.  However the two are not identical. In PAS the physician only supplies the means and need not be present at the time of death whilst in the above scenario the physician must not only be present but also deliver the lethal dose. Let us accept that the physician’s presence or lack of it is not relevant morally. However we must ask ourselves whether the fact that the physician supplies the means of dying differs in a morally significant way from the physician applying the lethal dose. It might be suggested that this a case in which we could use the principle of double effect to explain the difference. I would be reluctant to accept this suggestion. When supplying the means to die the physician involved in PAS has the intention of allowing the patient to kill himself, it isn’t a foreseen consequence of something else. The physician’s intention is the same whether he is involved in PAS or voluntary euthanasia as described in the above scenario. It seems provided the patient involved is able to initiate his own anaesthesia that there is no morally significant difference between voluntary euthanasia in these circumstances and PAS. Let us now consider a second scenario in which the patient is unable to initiate his own anaesthesia. I would suggest that there are no morally significant differences between a physician carrying out voluntary euthanasia on a terminally ill patient in this scenario and a physician suppling him with the means to carry out PAS provided the degree of voluntariness is the same in both cases. However is the degree of voluntariness the same in both cases? In the case of PAS the patient’s intentions seem to be clear because he initiates the dying process. If a patient can initiate his own anaesthesia I have argued he is initiating his death and once again his intentions seem clear cut. However if a patient is unable to initiate his own anaesthesia his intentions aren’t quite so clear cut. Perhaps this situation can be remedied by a rigorous consent process and a clear last directive. None the less differences remain between this scenario and the one in which the patient initiates his own anaesthesia and for this reason I would be reluctant to conclude that the scenario in which the patient is unable to initiate his own anaesthesia is equivalent to PAS. The above suggests some consequences for the process of deep sedation. Let us accept that the deep sedation of terminally ill patients who are unable to initiate their own sedation and voluntary are equivalent. It follows if we aren’t prepared to accept voluntary euthanasia we shouldn’t be prepared to accept deep sedation if the patient is unable to initiate his own anaesthesia.

In this posting I have argued that the deep sedation of terminally ill patients should be morally acceptable. I further argued such sedation was a legitimate use of medical skills. I have also assumed that most people would find such sedation acceptable and less contentious than either PAS or voluntary euthanasia. If most people find PA and voluntary euthanasia unacceptable and deep sedation is a legitimate use of medical skills then such sedation should be an option for the terminally ill. I then examined the moral implications of accepting deep sedation. The main implications of this acceptance are summarised below.

1. If we are prepared to accept deep sedation for terminally ill patients until death then we should be prepared to accept PAS when this process does not involve suffering.
2. If we are prepared to accept deep sedation until death and PAS involves some suffering then we should accept PAS provided that this suffering can be controlled without anaesthesia.
3. If we are prepared to accept deep sedation until death and a patient is able to initiate his own anaesthesia then in these circumstances we should be prepared to accept voluntary euthanasia.
4. If we are not prepared to accept voluntary euthanasia then we should not be prepared to accept deep sedation until death when a patient is unable to initiate his own anaesthesia.

Assisted Suicide and a Life not Worth Living

Writing in theconversation  Lidia Ripamonti asks if assisted dying became legalised who should decide if a life is worth living. She is assuming that assisted dying would become available to those who have a life not worth living. It might be argued because of dangers of pressure being put on disabled people, the aged and those suffering from mental illness that any such decision should not be solely up to the patient. If not the patient who else can say her life isn’t worth living? Her medical team, her priest or a bioethics committee? Others telling a patient she has a life worth living when she has already decided her life is not worth living seems to be unacceptably arrogant. In philosophy how we frame a question is especially important if we want to draw meaningful conclusions. In this posting I will frame the above question slightly differently. I will then argue that in certain situations we should simply accept the patient’s decision.

If we simply accept the framing of Ripamonti’s question then it is possible to conclude that there may be dangers for the disabled, the aged and the mentally ill if assisted suicide became permissible. I now want to suggest that her question might be better framed Perhaps the question might be framed as follows. If assisted dying is legalised, who gets to decide if someone’s life contains unbearable suffering rather than her experiencing a life which isn’t worth living? It might be argued that if the permissibility of assisted dying is based on unbearable suffering that disabled people and those suffering from mental illness would be better protected because they can live enjoyable worthwhile lives. It might be suggested that others, such as a patient’s medical team, might be able to give an objective answer as to whether the patient is suffering unbearably. Unfortunately it seems impossible to give an objective answer as to whether someone’s suffering is unbearable. One person might find some suffering bearable whilst similar suffering would be unbearable to someone else. Whether suffering is unbearable is a subjective question. Others telling a patient that she doesn’t have unbearable suffering when she has already decided her suffering is unbearable seems to be unacceptably arrogant. It might be suggested that this difficultly might be addressed by replacing unbearable suffering in our amended question by unbearable pain. Perhaps we can measure pain objectively. I’m doubtful whether this might be possible but let us assume for the sake of argument that pain can be measured objectively. However even if this was possible it doesn’t help solve our problem. What matters to some is not the degree of pain alone or how long it will persist but someone’s reaction to it. As with suffering someone might find a pain bearable whilst someone else might find the same degree of pain unbearable. It appears to follow if we don’t want to be accused of arrogance that we cannot replace a ‘life not worth living’ with either ‘unbearable suffering’ or ‘unbearable pain’ in an attempt to reframe Ripamonti’s question.

Ripamonti is concerned that letting the patient solely decide if she has an unbearable life endangers the disabled, the aged and the mentally ill if assisted suicide became available. I accept that Ripamonti is correct provided assisted dying became available across a broad domain. I will now argue that in a restricted domain her concern seem much less pressing. No one is suggesting assisted suicide should be available to anyone who finds her life not worth living. Medicine is concerned with illness not social problems. Let us assume that assisted suicide should only be available to terminally ill patients capable of making a competent decision. If we strictly restrict the domain of patients who could avail themselves of assisted suicide in this way the disabled, the aged and the mentally ill would appear to have little to fear from the legalisation of assisted suicide. Unfortunately this restricted domain appears not to be restricted enough, some terminal diseases may kill someone but can take a long time to do so. For instance Stephen Hawking was diagnosed with motor neurone disease MND in 1963 but lived a highly productive life until his death in 2018. Perhaps then the domain of patients who should be limited to those who are autonomous with a terminal illness and who are expected to live less than six months. Accepting such a domain should protect those suffering from Alzheimers, the disabled, the aged and those suffering from mental illnesses.

However accepting this strict domain causes additional problems which are not easy to resolve. If the domain is restricted to autonomous persons then this restriction protects those suffering from Alzheimers. We don’t, or can’t fully understand what it means to suffer from Alzheimers. But does it always protect children? Consider two patients suffering from terminal cancer both of whom suffer identical pain and find their lives not worth living. Let us assume that assisted suicide becomes permissible but is restricted by the above domain. Let us also assume that the first patient is an adult and as a result is able to end her suffering using assisted suicide. Let next assume that the second patient is a child who because of her suffering also wishes to relieve her suffering by ending her life. Children are not usually considered to be fully autonomous and we have restricted the domain of patients who can avail themselves of assisted suicide to those who are fully autonomous. It might be questioned whether we are really protecting the child. We certainly aren’t protecting her from pain and suffering.

I have argued that autonomous adults with a terminal illness with a prognosis that they will live less than six months and who believe that their life isn’t worth living should have a right to assisted suicide. However because I argued that assisted dying should only be available to autonomous patients creates difficulties and doesn’t protect some patients from pain and suffering. What sort of responses might be made to these difficulties? One response might simply be that I am wrong and that the decision as to whether a patient’s life is not worth living should not be solely up to the patient. Accepting this response would mean Ripamonti’s question becomes pertinent again, who should decide. However I would be reluctant to accept this response because of the reason given above. If someone who is expected to live less than six months believes her life isn’t worth living then it might be asked what pertinent reasons could have others advance to say her life is worth living? Of course others might advance other reasons pertinent to the impermissibility of assisted suicide but these reasons are not pertinent as to whether someone’s life is worth living. It would appear that the decision as to whether a patient’s life is not worth should be solely up to the patient. A second response might be to drop the requirement that the terminally ill patient must be autonomous. Of course how a decision is made to request assisted suicide matters. If such a decision needn’t be an autonomous decision should be replaced by a good decision, I have argued elsewhere that autonomous decisions need not always be good decisions wooler.scottus . Let us accept that a good decision is not simply some decisions regarded as a good decision by the decision maker. Others must also be able to regard the decision as a good decision. However if we accept the above the following might occur. The patient might make a decision that her life is not worth living which she believes is a good decision whilst others believe her decision is a bad one and not in her interests. Once again we might question whether the reasons others give for her life being worth living are pertinent. If others cannot give such reasons then there replacing an autonomous decision by a good decision becomes meaningless. I have argued that if assisted suicide became permissible that initially it should only be made available to autonomous adults with a terminal illness and a prognosis that they will live less than six months and who believe that their life isn’t worth living. I have further argued that who decides if a life isn’t worth living is the person living that life.

What can we learn from the above except that applied philosophy is a messy business? Can any practical conclusions be drawn from the above discussion? First I would argue that the discussion shows how a question is framed matters. Secondly a tight restriction on the domain of people who can avail themselves of assisted suicide gives rise to difficult questions. Such a restricted domain would protect the disabled from exploitation whilst enabling those disabled who meet the criteria to avail themselves of assisted suicide. However such a tightly restricted domain would not protect other vulnerable patients from suffering such as children and those suffering from dementia. None the less I would argue that it is better to protect a limited number of people from suffering than none. Perhaps more work might enable us to extend this tightly restricted domain to others but extreme caution would be needed.

The Philosopher's Dog

 

 A philosopher has a pet dog, does he do anything wrong? According to Gary Francione he does because a morally just world would have no pets, no aquaria and no zoos. Francione opposes pet ownership, zoos and aquaria because such things violate the fundamental rights of animals. In this posting I will only be concerned with pets and I will argue that Francione’s view is mistaken in cases involving some kinds of animals. I will next argue that the keeping of some pets can sometimes be mutually beneficial. Lastly in the light of these benefits I will consider the sort of animals it is permissible and possibly beneficial to keep as pets.

 I won’t consider a virtue ethics approach to the keeping pets because whilst virtue ethics might have something to say about how we ought to treat pets it has little to say about the permissibility of keeping pets. Neither will I consider a consequentialist approach. It might be objected problems of hungry people and environmental harm means we shouldn’t keep pets for consequentialist reasons. In what follows I will assume that either these reasons can be overcome or balanced by the benefits of keeping pets. In what follows I will examine three objections to pet keeping based on animal rights. First, a right to be free. Secondly, a right not to considered as property. And lastly, a right not to be kept in a dependent state.

 Pets unlike wild animals are confined to our home or to its immediate surroundings. It follows pets are restricted by their keepers from roaming freely. It has been argued that the inability to roam freely causes pets distress and that this distress means pet keeping is wrong. However, we don’t allow young children and infants to roam freely. Many five or six-year old children would like at times to roam freely and feel frustrated when their parents prevent from doing so. Frustration is a form of distress. Nobody suggests we shouldn’t have children because we curtail their freedom to roam might cause distress. It might be argued by analogy that the same is true of pets. It might be objected that this analogy doesn’t hold because once children become adults they can decide where they want to go whilst the same doesn’t apply to pets. In response to this objection I would point out that children develop skills which means they can enjoy their freedom. Feral dogs are free from restrictions but unlike adult humans they don’t appear to have the skills to enjoy this freedom. Pet dogs appear to flourish better than feral dogs. What is true for dogs need not of course apply to all animals. Some animals we keep as pets might be happier and flourish better if they were free to roam. However accepting the above means that there is at least one kind of animal which is not damaged if its freedom to roam is curtailed. It follows the argument against keeping of at least some kinds of animals as pets based on restrictions to their freedom fails.

 A pet is sometimes considered as someone’s property and it might be argued that owning an animal is wrong. This argument is really two different arguments. First it might be argued that someone can do whatever he likes with his own property and that he shouldn’t be able to do anything he likes to any pets he keeps. This argument is clearly false. Someone can only do whatever he likes with certain forms of property. Someone may do whatever he likes with his table and chairs. Pets even if they are property are not the kind of things someone can do whatever he likes with. Pets are living things and because of this the law prevents pet owners from mistreating their pets. Secondly it might be argued the simple fact of being owned damages pets? Certainly if one person owns another being owned damages the second person. This damage is due to a lack of freedom. In response to such an argument I would point out most pets are not persons. One possible exception would be a great ape and accepting the above would mean that keeping a great ape as a pet should be impermissible. Secondly as I have argued above for some sort of pets a loss of freedom doesn’t of necessity cause harm. It appears to follow even if pets are in some way owned this ownership doesn’t give us a reason not to keep some kinds of animals as pets.

 Lastly let us consider the dependency argument. If some creature is dependent on another this dependence means it is in a vulnerable position. Let us assume that it is wrong to place some creature in a vulnerable position. It follows we shouldn’t place any creature in a vulnerable position and that because pets are kept in a vulnerable position that it is wrong to keep pets. I believe the above argument is unsound. The premise that is it is wrong to place any creature in a vulnerable position is false. Pets exist and for most pets to be allowed to roam at will this would increase their vulnerability. The above argument might be refined by replacing the above premise with a related one. Let us assume that it is wrong to create some creature which will be vulnerable in life. Accepting the above would mean we might keep our existing pets but it would be wrong to permit the creation of any more. Once again I find the refined argument unconvincing because I believe the revised premise is also false. Human beings are vulnerable. I believe that we do have a duty not to bring into existence any being we think would not find its life worth living. I believe that this duty cannot be extended into a duty not to bring into existence some creature which will have a life worth living but is vulnerable in some way. It would appear that the dependency argument does not give us reason to keep some kind of pets provided that our lifestyle permits us to attend to their needs.

 I have argued that there are no reasons why we shouldn’t keep some types of animals as pets. I now want to argue that there are some good reasons for some people to keep some types of pets. Someone might keep a pet to showcase a lifestyle. Macho man keeps a big strong dog to demonstrate the sort of person he is. For such people pets have much the same status as their jewellery. I don’t believe keeping a pet to showcase a lifestyle is a good reason to keep a pet. Indeed I would suggest that this is a poor reason to keep pets because if someone wants to showcase the sort of person he is he should demonstrate this by his actions rather than his possessions. In spite of the above it should be permissible for such people to keep pets provided that they look after them well.

 One concern of moral philosophy is human flourishing. I now want to outline four empirical reasons why keeping pets might help some people to flourish. Firstly there seems to be a connection between keeping a pet with both physiological and psychological health, see the psychologist . Secondly keeping a pet might be useful in counteracting loneliness among some people, especially the aged. For instance walking a dog besides being beneficial to health increases the possibility of social interaction. Moreover even if someone is unable to exercise a dog keeping some sorts of pet might create a bond which could be useful in counteracting loneliness. Thirdly keeping a pet might be useful in a child’s development and help him to flourish for three reasons. Firstly children who actively care for pets, such as regularly walking a dog, might be more likely to develop a notion of responsibility. Secondly a more developed notion of responsibility might also foster a ‘caring for’ attitude. Thirdly there is some evidence that interaction with a pet might benefit some autistic people by reducing anxiety, see how animals can help autistic children . Verbal communication with a pet is a one way process. Lastly I would suggest that underlying all these reasons is a basic human need to love and be loved. This love of course isn’t romantic love but a very basic need to care about something. Indeed I would further suggest a failure to care much about anything is a failure to be fully human, someone who doesn’t care acts robotically or like a zombie. Caring about, or loving, makes us human and in some cases the keeping of a pet might help foster this caring about. Much more speculatively it might even be suggested that terrorists are unlikely to keep pets or have kept pets as children. Maybe loving a cause tends to exclude someone from loving a pet and vice versa.Perhaps this somewhat bizarre suggestion could be tested empirically.

 Let us accept that it is permissible, perhaps sometimes even desirable, for someone to keep a pet. However does this apply to all animals or only to a subset of animals? What sort of animal it would be morally permissible to keep as a pet? I argued above it is permissible to restrict the freedom of certain animals such as dogs. Dogs, cats and perhaps a few other animals such as horses have adapted their way of life so they can still flourish when restricted by humans. Most wild animals would not cope well if their freedom was restricted and it would be wrong to keep such animals as pets. Let us accept that it is only morally permissible to keep as pets animals that can still flourish when restricted by humans. I now want to consider a slightly different question. What sort of animal might benefit someone if kept as a pet? I have argued above that our need to love and be loved gives us a reason to keep pets. What does accepting the above tell us about the sort of animals we should keep as pets? Let us examine our need to be loved first. Intuitively a dog can love someone whilst a fish can’t. Why is this so? I would suggest the reason is evolution has changed some animals so they can adapt to our lifestyle. Someone merely feeds fish and cleans their tank because fish haven’t adapted to our lifestyle. The same isn’t true of dogs. If we accept the above, then the type of pets we have reason to keep for the benefits they give us is limited. We have reason to keep dogs, possibly cats or even ponies but not many other kinds of animals. We definitely don’t have reason to keep snakes or fish based on our need to be loved. However, we don’t simply have a need to be loved we also have a need to love, to care about something. Is it possible to love a snake or a fish? I will now argue it isn’t. I would argue if we love something we must be capable of benefiting what we love. By love I mean ‘caring about’ and not simply ‘caring for’. Of course ‘caring about’ and ‘caring for’ are connected and there is a spectrum between these two forms of caring. However, if I care about something I am benefitted when what I care about is benefitted and harmed when what I care about is harmed. The same is not true for ‘caring for’ something. I can benefit a fish by feeding but not feel benefited myself. Let us consider benefits in more detail. If someone plays with a dog and a ball he is happy because his dog is happy, much the same applies to someone stroking a purring cat. However, someone might know what harms a fish or snake but he has little or no idea about what makes these creatures are happy. She doesn’t know what benefits these creatures besides ‘caring for’ their basic needs. Someone might care for such creatures but he can’t ‘care about’, love them. It follows someone’s need to ‘care about’ love cannot be satisfied by keeping animals like fish and snakes as pets and that this need to love cannot used as a reason to justify keeping them as pets.

 In conclusion it seems that it is perfectly permissible for a philosopher to keep a dog as a pet. It might also be desirable in some cases for some people to keep a pet, especially children. However the sort of animals it is permissible to keep as pets is limited to those animals who have been shaped by evolution to fit our lifestyles.