Sleight of Hand - Schiavo and the Euthanasia/Withdrawal of Care Distinction

I want to address this argument from Rivka at Respectful of Otters, in which she makes a moral distinction between allowing yourself to die and killing yourself (or, more exactly, between allowing someone else to die according to their wishes and killing them, also according to their wishes). 

She starts by making the case for personal autonomy as the basis for the right to decline life-saving treatment: "No one has the responsibility to submit to everything that medical science could potentially do to prolong life. As individuals who own and have sovereignty over our bodies, we have a fundamental right to bodily integrity." She then gives a list of examples of situations in which someone might choose to decline medical treatment and writes, " We have the right to say 'enough,' and let the natural dying process take its course. We have the right to have the integrity of our bodies unviolated by unwanted medical treatment - just as we have the right to insist on aggressive efforts for life extension. We have the right to choice. And when we are no longer able to exercise that right ourselves, we have the right to designate our closest others to do so on our behalf."

"To define the exercise of that right as 'killing' is to pervert the end of life unimaginably." She then relates the story of her grandfather choosing to die at home, although heroic measures in the hospital might have extended his existence a few days.  She says that her grandfather's decision was entirely rational.  " But who would have benefited had my grandfather been forced to squeeze out a few extra days in an intensive care unit, on a respirator, confused and disoriented? In what way would that have furthered a culture of life?"

The nut of her argument then follows:

The natural course of life ends with death. To allow that natural process to take its course is profoundly different than hastening it along. Asking others to refrain from interfering with nature is profoundly different from asking them to make, or be complicit in, the decision that nature is not progressing quickly enough - as in euthanasia or physician-assisted suicide. Euthanasia asks the physician to play God, to decide whether another person's life is sufficiently without value that it should be actively terminated. The cessation of life support asks the physician to stop playing God, to refrain from intervening further in a disease process which has its natural terminus in death.

She concludes by saying that the evidence of Terri Schiavo's intent has been weighed and re-weighed, that the evidence shows that her "wish would have been to remain unviolated by a feeding tube if she had no hope of recovering", and so her will should be carried out.

My difference with Rivka's argument is that I doubt, morally and practically, that "allow[ing] that natural process [of dying] to take its course is profoundly different than hastening it along."  I think that making the distinction between withdrawing care and active euthanasia is important to people who believe that the dangerous principle of personal autonomy has to be cabined.   It's also a helpful way to sell the principle of personal autonomy to those who would never accept its logical conclusion - namely, that people should have the right to end their lives whenever they choose. 

The moral distinction Rivka makes rests on two smaller distinctions: action versus inaction, and natural versus artificial.  Both of those, I think, are smaller than meet the eye, especially  in the medical context. 

One always has the right to not seek medical care, Rivka says, even knowing that doing so will cause you to die sooner than otherwise.  I agree.  I can go my whole life never visiting a doctor and expire, clutching my chest during a fit of apoplectic rage, in front of my computer.  (In fact, I just might, someday, although I aspire to be shot by a jealous man.) In the context of terminal illness, how is the action/inaction distinction relevant?  When a patient's condition reaches a certain point, agreed upon in advance, the doctor withdraws hydration and nutrition.  Everyone knows - indeed, the whole point is - that in a few days the kidneys will start to shut down, followed by other internal organs, ultimately resulting in death.  This is not "doing nothing", this is taking an active step to end life.  It makes more sense to me that the doctor would simply give the patient an injection to stop the heart.  In both cases action is taken that is known, expected, desired, to end the life of the patient.  To call one "respecting the right of personal autonomy" and the other homicide is somewhat silly.

In withdrawing care, one can take comfort in the belief that the patient died of natural causes instead of by unnatural means.  It is true that renal failure is a natural cause of death when the patient is not getting any water.  But it is the doctor's hand that prevents the administration of water.  If you can't get any air, you will suffocate.  That's natural.  If you can't get any air because my hand is over your nose and mouth, ordinarily we would not say you died of a natural cause.  The fact that there is a delay between the doctor's action and the consequence does not reduce the doctor's moral agency. When you know the effect of what you will do, then whether your means are a quick lethal injection or the slow effect of turning off a tap is really irrelevant. 

I think I understand why Rivka and others like the distinction she makes.  Most people, especially most Christians, are uncomfortable with suicide.  But the Enlightenment concepts which have led to the exaltation of patient autonomy seem irrefutable.  In order to prevent - or at least forestall - the arrival of the day when a patient can successfully request that their life be terminated, the arbitrary line between withdrawing care and administering lethal medication is preserved as a fig leaf. 

Also, of course, many people worry that the doctor (or the patient's family, as in the Schiavo case) will order death when the patient would not have wanted it.  But the withdrawing care/euthanasia distinction is inapposite to that concern.  The crux is a worry that there is insufficient proof of what the patient would have wanted, and that worry exists whether you are withdrawing a tube or inserting a needle. If sufficient proof of intent is desired, mandate a standard of proof you would accept rather than proscribing certain means for carrying out that intent.  Perhaps, again, the length of time required for withdrawing care to do its job gives a false reassurance.  It seems "natural", so we demand a lower standard of proof.  Maybe the longer period of time gives the sense that anyone who objects will be able to raise their opposition before it's too late, giving the whole thing a gloss of due process by which we believe good decisions will be made. Or maybe the emotionally charged, drawn-out process of dying drains the guilt and sense of responsibility from the person who has ordered that the patient's wish be carried out, simply by exhaustion.  Call it pre-grieving, but whatever it is, it works.

I don't want to come off like I am criticizing Rivka or anyone else who likes the withdrawal of care distinction too much.  I think half a loaf is better than none, and I would much rather have this much patient autonomy than none at all.  Also, I am not an ethicist or a doctor, and so this is not my field.  But I do think it is worth considering whether we are perpetuating an incoherent standard, and whether we can continue to live with the incoherence or whether it is time to resolve it.

***

In actual Schiavo-related  news, there is no joy in Red America today.  To the surprise and dismay of every idiot in the country, a federal judge has turned down the opportunity to grant an order re-inserting Terri Schiavo's feeding tube.  Even with Bush's new super-special federal question law, the judge thinks that since 9 judges over 7 years have considered - and rejected - the parents' claims, there is little likelihood that their assertion of denial of due process will succeed.  Huh.  Go figure.

How the hell all that will turn out I have no idea.

Comments

[doctorannie]

The ethical distinction here is not about the dying. Certainly someone is just as dead whether they are suffocated or denied supplemental oxygen. The distinction is in the "killing". Watching someone die and doing nothing to stop it is not the same as murder. That is what the withdrawl of treatment is - it is resuming a course of doing nothing. That may entail an active step, but ethically it is no different than not initiating care to begin with. Euthanasia is ethically a different question entirely. That isn't to say it is always wrong, but it falls under the category of "acceptable" murder, like war or capital punishment (not acceptable to me, but to many others). There is no consensus in our society or in the medical community about if or how euthansia would be acceptable.

[Mithras]

That may entail an active step, but ethically it is no different than not initiating care to begin with.

Right, but in the terminal patient case, you've almost certainly done a great deal of care already. The way I see it, in both the withdrawal/lethal injection scenarios there are three steps:
1. Doctor to patient: "When I become terminal and unconscious, I want you to do X, so that I don't linger unnecessarily."
2. Doctor to patient: "I agree to carry out your wishes."
3. Patient becomes terminal and unconscious, and doctor does X.
Whether X is withdrawing a hydration tube or injecting potassium chloride is really just a detail.