Tuesday, June 12, 2007

Euthanasis and Medicine: Intro

Much philosophical discussion about euthanasia centres around abstract questions such as the moral autonomy of the patient. But are such interests protected by the medical establishment? Can they even be profitably discussed independently of professional considerations?

Those who militate for, to use a clear example, legal euthanasia to be available on a "voluntary" basis (one feels grateful for this qualification!) often argue that such ministrations can be carried out more humanely and responsibly within a clinical context. But I want to explore what assumptions relating to the nature and utility of institutionalised medicine this idea is based on. For the contention seems to be that many concerns harboured by opponents of euthanasia would be assuaged if the 'mercy killing' takes place within a well designed, best-practice clinical procedure and context.
But is this true? Proponents of active euthanasia often maintain that within a controlled clinical environment, there is little risk of a patient being killed in the absence of his or her full and unqualified informed consent. Systems have been developed whereby terminally ill patients may elicit their own deaths in order to cease their suffering by administering a lethal injection via an apparatus controlled by a computer programme. This programme allows the patient ample opportunity to abandon the procedure and continue to live towards their ultimate natural demise. Patients are also unequivocally reminded of the gravity of the act which they are preparing to undertake (that might not be necessary!). These mechanisms, their proponents claim, guard against many of the scenarios feared by individuals opposed to euthanasia coming about.

I think it is profitable to examine, however, what the employment of this technology can show us about the current state of the euthanasia debate. These procedures operate within a technologically-ordered social structure; specifically, institutional medical care in a hospital. Thus the debate rages over an issue within a specific cultural context, and within a peculiar institutional paradigm. As a consequence very often from philosophical writing about euthanasia we find absent any discussion of the proper purpose and place of medical care. This would seem to be a singularly odd phenomenon, given the extent to which questions surrounding the issue of euthanasia belong to the province of medical ethics.
It seems to me that it is quite strange how we blithely take the status of medical care as a given. For a necessary prologemenon to an ethics of euthanasia qua clinical procedure must surely be a discussion of the proper purpose of medical care. And if this preliminary enquiry is going to be sufficiently robust, it will inevitably be partly given over to a substantive critical discussion of the genesis of prevailing attitudes to medical care. A significant proportion of the recent philosophical literature regarding euthnasia, however, sees the issue as universal, rather than within a particular set of institutional frameworks.
We see, for instance, the arguments of those who are predisposed to denying a reasonable distinction between active and passive euthanasia. In his famous article, the late James Rachels averred that since a man who watches a young child accidentally drown himself in a bath and maliciously chooses to take no action to assist him is equally culpable to a man who forcibly submerged a child into water to procure is death, there is no reasonable differentiation to be made between active and passive euthanasia.
But by aligning the withdrawal of medical care to a terminally ill patient with the callous killing- whether by force or acquiescence- of a young child, Rachels elides any consideration of the proper place, puposes and effectiveness of medical care. Arguments such as his seem to betray a thoroughgoing Western professional imperialism. Why ought we not look at how the right to opt out of, or to question, the medical treatment that is offered by doctors, and the ideas that inform current medical orthodoxy in our culture? The autonomy of the patient seems central to the euthanasia issue. For the very question of voluntary active or passive euthanasia arises within a medical context. As such it must be related philosophically to the very reality of day-to-day clinical environments. To fail to do so is to engage in philosophical extravagance, divorced from the reality of the situation in which the issue arises. I will examine this further in later posts.


David Hunter said...

Hey Thomas welcome on board. As just a wee bit of house keeping I've inserted a break in your post so that those who are interested can choose to read the whole thing.

Very interesting first post, and I do agree the context may be important to discussing the ethics of euthanasia. That said I could see someone arguing that actually euthanasia is just a special form of suicide and so is more general than just the clinical context or the proper purpose of health care.

Still I look forward to your further posts.


Thomas Harvey said...

Thanks David. I have anticipated your objection, so watch out for next time!

robert said...

This post raises an important issue. Questions about medical professional authority and the context of care are discussed in a recent collection, Surgically Shaping Children, which I have reviewed for the mental health net. There I made a point in response to urgings that children be given more 'say' in surgical decisions that the operational machinery of securing consent could incorporate such a requirement without altering the basic power relations involved. I had thought of extending the question to PAS and I;m glad to see you have raised the issue.

As a stab at starting to specify the institutional roles involved, here's three models to consider: medical professional who knows best for patients, medical professional who has a consultative role, and medical professional with technical skills for hire.

As a long time mdical professional, I did not see myself operating in the third model - aimed at the second - but am sure I did not avoid the first.

Final comment: I don't see how to infer Western imperialism from Rachels' sparse narratives. I thought his goal was to cast doubt on an alleged theoretical distinction between killing and letting die that he seems to argue is not actual.

Thomas Harvey said...

Thanks for your comment Robert. I suppose all I can say since I've nort yet had an opportunity to complete my next post is that your "Medical Professional with Skills" model doesn't really apply to the question of euthanasia since the entire debate arises out of a clinical context! This seems to be recognised by many voluntary active euthanasia proponents (hence the Northern Territory system I cited).

With specific reference to Rachels, many have argued, I think convincingly, is that his argument rests on the total propriety of the analogy between killing/withdrawing medical treatment and watching the kid drown/drowning the kid yourself. As soon as some disanalogy is shown, where is the substance of the argument?

Anyhow, I hope to post again on this on the weekend.