* For an assignment for my ethics class with Dr. Scott Rae for the MA in philosophy program at Biola University.
** For another study on issues related to this see my "Life, Death, & Growing Old (Part 6): End of Life Issues"
Case 8.1: Your Father’s Living Will
Your elderly father has recently been diagnosed with terminal lung cancer. His doctors estimate that he has roughly a year left to live before the cancer will overtake him. His is wisely using this as an opportunity to think about what kinds of treatments he wants or wants to refuse as the cancer runs its course. He has seen several of his friends die on life support in hospitals and wants to make sure that he doesn’t die that way. He is asking you to be his medical decision maker should he lose the ability to make those decisions for himself. Specifically, he does not want to be on ventilator support, especially if it looks like he cannot be weaned from it. You realize that means that he may die sooner than if he were on such support, and you wonder if you can do that, given your strong view of the sanctity of life. It feels as if you would be killing you dad if you authorized the withholding or withdrawal of ventilator support. He has maintained that if his life gets too painful or has suffering that can’t be alleviated, he wants to have the option of physician-assisted suicide, since it’s legal in the state in which he resides.
Questions for Discussion
1. Do you think it is acceptable to remove or withhold a ventilator from your father in his condition, even if it means he will die sooner? If not, why not? If so, under what conditions is it acceptable?
2. Do you believe that removing a ventilator would be killing your father? Would it make you complicit in his death? Why or why not?
3. Your father also does not want to be on feeding tubes for his nutrition and hydration should he lose the ability to swallow. Would you consider feeding tubes the same as ventilator, or are feeding tubes more basic care? Is removing the feeding tubes the same as starving someone to death? Why or why not?
4. Assuming you live in a state where physician-assisted suicide is legal, would you help facilitate physician-assisted suicide for him? Why or why not?
This case raises all sorts of ethical issues for end-of-life decisions. Movement forward can be found in carefully delineating crucial distinctions that will help clarify the ethical boundaries within which one should move. The following distinctions will be highlighted: (1) Withholding versus withdrawing treatment, (2) Killing versus letting die, and (3) Removing a ventilator versus removing feeding tubes. Furthermore, a consideration of physician assisted suicide will be briefly examined.
Distinction One: Withholding/Withdrawing Treatment
The first distinction to note in this situation concerns that of withholding treatment and withdrawing treatment. Many ethicists recognize that there “is no significant moral difference between the two.”[1] If there is a legitimate place for informed consent in refusing a treatment then there is also a morally appropriate place for withdrawing that treatment. Although there is no morally relevant difference between the two there may be an emotional difference that is felt. As Scott Rae notes, “The reason for this emotional difference is that the family sees their loved one being maintained on life support, and the decision to withdraw it often feels more like they are causing the death of their loved one.”[2] The issue of whether one is causing the death of a loved one by withdrawing treatment will be taken up below under the distinction between “killing and letting die.”
If the above is correct, then it is important to examine what morally legitimate reasons there might be to forgo medical treatment.[3] The usual course of action is to pursue medical practices and procedures which elongate life with the goal of moving one toward healing and restoration. There are situations, however, in which these goals cannot be met, and the prolonged use of certain medical practices and devices actually diminish the earthly goods intrinsic to life. Some of these intrinsic goods might include “physical comfort, the fellowship of family and friends, and the ability to work and play.”[4] In light of these considerations the following guidelines can be offered as to when forgoing treatment is morally allowable:
1. When a competent patient requests it.
2. When the treatments are futile.
3. When the burdens of the treatment outweigh the benefits.
Regarding number two—the issue of “futility”—Rae helpfully articulates a specified notion of “futility” in this context: “But more broadly, treatments are futile if they will not reverse an imminent and irreversible downward spiral toward death for the patient. To put it another way, treatments are futile if they will not restore the patient to an acceptable quality of life.”[5] This appears correct, with one caveat regarding the phrase, “quality of life.”
VanDrunen correctly notes that the phrase “quality of life” is “a slippery phrase that different people use in different ways.”[6] His thought here is worth quoting in full:
Some people use the idea of “quality of life” to ask whether certain sorts of lives are no longer valuable or not worth living. For example, suppose that a course of treatment would prevent me from dying but result in a poor quality of life, because it would lead to physical discomfort and prevent me from performing many activities that I enjoy. Should I forgo treatment because I would be better off dead than experiencing such a life? I suggest that this is a morally problematic use of the “quality of life” idea. All human life is valuable and… it is never our prerogative to seek death because of despair and discouragement. There is a better use of the “quality of life” idea, however. It is proper to ask whether life without treatment or life with treatment would be better. The question is not about choosing life or death, but about choosing which sort of life (though we know that one choice might bring death sooner).[7]
With this caveat in view, the criteria can be appropriately applied to the case under consideration.
Before applying all the above to the case under consideration, one more factor ought to be considered—the age of the father. He is an elderly man. This is a relevant factor considering the nature of death. In Scripture death is seen as both an enemy (1 Corinthians 15.26), in that it is not an original intention of our Creator for humankind but, rather an alien intrusion into his good creation, as well as a natural part of the cursed created order under sin (Romans 3.23; 6.23). Death’s normalcy and even the usual set time frame for a life is a settled reality for those who live in a cursed word. Even someone who accords no value to the scriptural testimony can feel and see this two-edged perspective on death. There is a general fear of death and an empirical reality to the extent of one’s lifespan. With this understanding, “We instinctively judge that a child’s death at age nine is a tragedy in a way that an elderly person’s death at age ninety-nine is not.”[8] All of this should be factored into the decision to forgo treatment. As VanDrunen notes, “A person at an advanced stage of life cannot expect a significantly longer life even with treatment. Nor can she expect, even under the best circumstances, to be able to pursue the range of human goods that a younger person could.”[9]
This case is specifically about an elderly man who has been diagnosed with terminal lung cancer and has about a year to live. He is fully cognizant of his medical situation and has also seen friends die on life support in hospitals and does not want to die in that manner. In particular, he desires to avoid being put on a ventilator, especially if it appears that he will be unable to be weaned off it. The decision by the man himself or his proxy appears to a morally acceptable one. Of course, there could be underlying motives and intentions, unstated and undetected, that would sully the morality of the decision but the proxy who has strong beliefs about the sanctity of life ought not to feel guilty (since there is no moral guilt in the action) for removing his elderly father from the ventilator. This leads to the second crucial distinction to be considered—the distinction between “killing” and “letting die.”
Distinction Two: Killing/Letting Die
Even if one is morally justified in removing one’s elderly father off the ventilator as per his stated intentions, is this act equivalent to killing him? James Rachels and others argue that the distinction between killing a person and letting them die is not morally relevant. The thought experiments brought up to justify this line of thinking drop out key elements of ethical analysis. The most prominent element overlooked by Rachels, and others, is the intention of the moral agent involved. Looking at only the overt action and failing to consider the moral relevance of intentions and motives renders this approach to moral analysis shortsighted. This becomes crucial to examining the key difference between terminating life support (TLS) and physician assisted suicide (PAS). In TLS the aim is not necessarily to bring about death whereas in PAS this is the explicit aim of the patient and doctor. Rae helpfully distinguishes between intendingdeath, foreseeing death, and accepting death.[10] The patient or proxy acting with the consent of the patient is not seeking death as the primary target—he is not intending death. However, in the act of TLS, he does foresee death coming and accepts this consequent result.
In accordance with this analysis, VanDrunen helpfully notes that the choice for TLS is not aimed at death, but at a different kind of life. In the situation of a terminal case like the one being examined, the decision to forgo certain medical interventions may not be a decision to die. VanDrunen argues as follows, using the example of cancer and the patient’s forgoing of chemotherapy:
The fact of death has already been decided, apart from the cancer victim’s will. Instead, the choice to forgo more chemotherapy may be a decision to live a somewhat shorter life than the chemotherapy might make possible, but a shorter life that is free from the debilitating burden of chemotherapy and that enables the person to enjoy her remaining life more—to finish projects, to spend time with loved ones, and to get her house in order. It is not necessarily a choice between life and death, therefore, but a choice between one kind of life and another kind of life.[11]
Thus, the distinction between active killing and letting someone succumb to imminent death is a valid one.[12]
Distinction Three: Removing the Ventilator and Removing Feeding Tubes
This case study also asks for consideration of the removal of feeding tubes or, more accurately, artificial nutrition and hydration (ANH). Some ethicists find that there is a morally relevant distinction between removing ANH and removing a ventilator. Whereas the removal of the ventilator under certain conditions is morally allowable, the removal of ANH is never justified morally. The most common situation consider in this regard is the person in a persistent vegetative state (PVS). For the person in a PVS, the removal of ANH is still immoral.
This view is not above criticism. It is important to recognize the situational details regarding ANH. Scott Rae is careful to articulate the use of ANH as “medically provided nutrition and hydration” with a key stress on the concept of “medical.” He helpfully writes:
The phrase “medically provided nutrition and hydration” is used intentionally to underscore the technological nature of the treatment. There is a strong parallel to the ventilator insofar as medical technology is performing an essential function that the body, through injury or disease, can no longer perform itself. Certainly, air to breathe is as basic a human need as food and water. Yet very few question the morality of removing a ventilator under certain conditions since it is considered legitimate medical treatment.[13]
Although there is continuing debate among ethicists on the matter, Rae’s reasoning is sound. There is not a significant distinction morally between the removal of a ventilator and the removal of medically provided nutrition and hydration.
Physician Assisted Suicide
In reference to the case study thus far, it has been argued that (1) there are legitimate reasons to terminate life support, (2) the termination of life support is not equivalent to killing, and (3) in certain situations there is not a morally relevant distinction between the removal of a ventilator and the removal of medically provided nutrition and hydration. Therefore, the elderly father and his son acting as proxy may plan for and implement the withholding or withdrawal of a ventilator. The case study also raises the possibility of the use of physician assisted suicide (PAS) in a state where such is legal. Might it be the case the move from TLS to PAS is also morally legitimate?
It is here that a moral boundary is crossed in that use of PSA is morally problematic. It is helpful to remember that PSA is a subset of the general category of suicide. From a Christian perspective, suicide is an immoral act of taking one’s own life.[14] PAS is aimed at producing the death of the patient. As such, the elderly father in the case study should be encouraged to refrain from pursuing the assistance in suicide from another and the son should not countenance PAS a valid moral choice. The father should be counseled on the legitimacy of TLS and options available. Furthermore, pain-reduction strategies should be surveyed with the father and son as they are clear on morally appropriate options available that fall short of PAS. Besides standard pain management controls (i.e., morphine) there may be other options which are available which do not intentionally aim at death. For example, the “sleep before death” option, in which the patient is sedated before they die, or the use of the doctrine of double effect, in which the amount of pain medication may be increased as needed to control pain but nonetheless knowingly brings about the death of the patient, may be utilized.
This brief essay has examined three crucial distinctions necessary to analyze this case study in an ethical manner. The first distinction of withholding versus withdrawing treatment was found to be a distinction without morally relevant significance. Reasoning which would allow for withholding a treatment ought to be considered for withdrawing treatment. A brief review of the circumstances in which one would be morally allowed to withhold or withdraw treat was considered. The second distinction of killing versus letting die was found to be a crucial distinction to uphold as morally relevant. The two acts cannot be collapsed into one another. The chief reason for this is that doing so fails to account for the key ethical element of intentionality. The third distinction concerned whether the removal of medically provided nutrition and hydration was in a different moral category than the removal of ventilator for a patient. Although there is dispute on this issue, it was argued that there is not morally relevant distinction that needs to be taken into consideration. A brief examination of physician assisted suicide was also offered with the conclusion that PAS was morally unacceptable, whereas there were other morally acceptable options available for consideration.
[1] Scott B. Rae, Moral Choices: An Introduction to Ethics—4th ed. (Grand Rapids, Mich.: Zondervan, 2018), 239. David VanDrunen writes: “In my judgment, the proposed distinction between withholding and withdrawing treatment is not morally significant, and it is not possible to identify different sets of criteria for evaluating each one. As some writers have noted, insisting upon the moral significance of this distinction may have the unintended negative effect of discouraging people from beginning useful treatments because they fear they will be bound to a course of treatment that they will not be able to refuse at a later date.” David VanDrunen, Bioethics and the Christian: A Guide to Making Difficult Decisions (Wheaton, Ill.: Crossway, 2009), 216.
[3] The use of the word “forgo” is intentionally following VanDrunen who uses this word “as a general term that includes both ‘withholding’ and ‘withdrawing.’” VanDrunen, Bioethics and the Christian, 216.
[12] VanDrunen offers an insightful note at this point: “I would concede that there are certain circumstances in which a decision to kill actively and a decision to let someone die when it is in our power to prevent it are equally morally reprehensible. The example of the child in the bathtub may well be an example of this. In the medical context, we might imagine a doctor who dislikes a patient and wants her dead, despite the fact that she desires to be healed and has a curable illness. We would probably condemn this doctor just as strongly if he intentionally withheld a treatment necessary to prevent her death as if he secretly gave her a lethal injection. But even in such carefully constructed scenarios in which the moral guilt attaching to two different courses of action seem to be equal, the two different courses of actions themselves are not the same. If one of my neighbors shouts an insult at me from across the street and another neighbor steals a flowerpot from my front yard, I might judge that they have wronged me in equally serious ways. But I would not therefore conclude that there is no meaningful moral distinction to be made between insulting and stealing. They are different moral actions and require a different moral analysis for understanding and evaluating them properly.” VanDrunen, Bioethics and the Christian, 208-209.
[14] If someone does not accept the Christian perspective then the form of ethical reasoning may need to start farther back and seek to demonstrate the moral unacceptability of suicide from a kind of natural law argument or, perhaps, from consequentialist considerations. Nevertheless, the presentation of a Christian argument against suicide demonstrates the internal coherence of the Christian ethical viewpoint and allows for the manifestation of truth about God, humanity, and the human predicament. For a fuller presentation on the Christian perspective on suicide see my lesson, “Life, Death, and Growing Old (Part Four): Suicide” White Rose Review (July 20, 2016)—online: http://whiterosereview.blogspot.com/2016/07/life-death-growing-old-part-four-suicide.html.
