Introduction

Part 2

Part 3

Appendices

Part 1

Introduction to Part 2

Introduction to Part 3

     Appendix A

Introduction to Part 1

     Chapter 6

     Chapter 9

     Appendix B

     Chapter 1

     Chapter 7

     Chapter 10

     Appendix C

     Chapter 2

     Chapter 8

     Chapter 11

     Appendix D

     Chapter 3

Conclusions to Part 2

Thesis Conclusions

     Appendix E

     Chapter 4

     Appendix F

     Chapter 5

Bibliography

Conclusions to Part 1

Books and Articles

Legal Cases

 

Part 3: Introduction

 

 

“Who is there today who still cares about a well-finished death?  No one ... the desire to have a death of one's own is becoming more and more rare.  In a short time it will be as rare as a life of one's own ... You come, you find a life, ready-made, you just have to slip it on.  You leave when you want to, or when you are forced to: anyway, no effort: Voilŕ votre mort, monsieur. ... [in times past] you knew that you had your death inside you as a fruit has its core.”

Rilke [i]

 

 

The conclusion to Part 2 of this thesis[ii] was that the Ward case - not because of its decision to permit the withdrawal of ANH per se, but because of the grounds used to justify this decision - risked developing a 'slippery slope' in which the withdrawal of life-sustaining treatment could be withdrawn from disabled patients on the basis of their supposed poor ‘(absolute) quality of life’.  The goal of this part of the thesis is to develop a conceptual scheme which will permit cases such as Ward and Bland, to be resolved without the risk of developing a 'slippery slope'.  More particularly, a conceptual structure will be developed which will enable the withdrawal of life-sustaining treatment, including ANH, to be justified in cases of PVS or ‘near- PVS’ but not in cases of disability such as that of a Down Syndrome infant with an easily curable intestinal blockage (as in Re B [iii]).  A case such as Frenchay v S [iv] - in that there was some tentative evidence that the patient had an ability to communicate - would mark the boundary between cases where withdrawal of life-sustaining treatment is permitted for reasons of ‘best interests’ and cases where such decisions negate[v] a patient’s rights.

The structure to be developed depends on two concepts: ‘death’ and ‘personhood’; from these concepts three strands will be woven:

(i)   The concept of ‘a good death’:

It will be argued that the proposition ‘Death is an evil’, if unqualified, is unsustainable; it follows that some deaths are a ‘good’; the conditions under which a death may be called ‘a good death’ will be clarified.

(ii)  A necessary condition for the ascription of personhood:

It will be argued that the ‘ability to communicate to some minimal standard’ is a necessary condition for the ascription of personhood.

(iii) Obligations flowing from Justice as distinct from those flowing from Charity:

I have adopted and developed a distinction (used by Phillipa Foot [vi]) between the obligations that flow from the virtue of Justice and those that flow from Charity.  A term is introduced - ‘Objects of Intrinsic Moral Worth[vii] - to describe those objects/individuals to whom obligations are due based on Charity.  Those to whom obligations are due based on the virtue of Justice are called ‘persons’ (the obligations are called ‘rights’).  It will be argued that the obligations flowing from Justice preclude any steps being taken, whether by act or omission, to end the life of anyone to whom such obligations are owing without their consent; obligations flowing from Charity (i.e. ‘moral obligations’ and which - in the context of medical care - are to always act in the best interests of a patient), in contrast, carry no such implications in relation to the causing of death provided only that the actions are motivated solely by compassion.

 

A summary of the argument to be developed

 

PVS patients, in that they have permanently lost the ability to communicate, have lost their personhood.  However, (as argued in Part 1) [viii] such patients must be treated as if they are conscious; hence - in so far as the possession of consciousness or the ability to feel pain is accepted as a criterion for being an ‘Object of Intrinsic Moral Worth’ - PVS patients are ‘OMW’s’.  Thus, whereas obligations owing to PVS patients based on Justice have lapsed, those based on Charity still persist.  Accepting Foot’s argument that intentional killing offends both against Justice (in that it is a non-consensual interference) and Charity (in that it does not flow from motives of compassion); it follows that the killing of a PVS patient, if done solely from motives of compassion would not offend against either virtue. 

The meaning of the term ‘a good death’ is examined and it is argued that a moral obligation exists on medical carers to enable a patient to achieve ‘a good death’.  It is argued that the intentional killing of a person against their wishes could never constitute ‘a good death’; however, it may constitute ‘a good death’ if - as in cases of assisted suicide - it is consensual; even then there may be weighty social reasons, as Foot has argued, for prohibiting such intentional killing of persons. 

The non-consensual, intentional, killing of individuals who have lost their personhood (such as PVS patients) may constitute ‘a good death’ if the killing is motivated solely by compassion and done solely in their ‘best interests’.[ix]  Thus, there may in certain circumstances be an obligation on medical carers to kill their patient.  This conclusion, however, is based only on an analysis of the rights and obligations of the patient[x] and their medical carers; other parties[xi] are also affected by such decisions and the inclusion of their interests in the ethical equation may ensure that intentional killing is deemed to be unjustified in all circumstances.[xii] 

One important consequence of this analysis is that the making of a medical treatment decision for a patient who is not permanently unable to communicate (for example, a Down Syndrome infant who will, in time, have the ability to communicate to the requisite standard[xiii]) which forseeably results in the death of that patient is effectively an annihilation of their personhood and as such is morally equivalent to their murder; this is so even if the decision is made in the patient’s ‘best interests’ and motivated solely by compassion. 

 

Structure of Part 3

 

Part 3 is divided into three chapters and three appendices:

 

Chapter  9 :

examines the concept of ‘a good death’.

Chapter 10 :

considers the concept of personhood and establishes a necessary condition for its ascription; the concept of ‘Objects of Intrinsic Moral Worth’ and Foot’s analysis of the obligations flowing from the virtues of Justice and Charity are also discussed.  

 

 

 

Chapter 11 :

sets out and develops the conceptual structure being proposed in this thesis.

 

 

 

 

 

Appendix D :

contains a summary of Foot’s essay on euthanasia.

Appendix E :

examines the development of euthanasia in pre-war Germany.

Appendix F :

contains summaries of some modern definitions of personhood.

 


 



[i] Rainer Maria Rilke, The Notebooks of Malte Laurids Brigge, p.9-10.

[ii] See Part 2: Conclusions; also Conclusion 8 - 6 to Conclusion 8 - 11 inclusive.

[iii] Appendix C - number 7.

[iv] Appendix C - number 3.

[v] not only ‘negate’ but - as will be argued - effectively revoke all of the patient’s rights and thus destroy their personhood.

[vi] In her essay ‘Euthanasia’ included in Phillipa Foot, Virtues and Vices. pp 33-62; this essay is summarised in Appendix D.

[vii] ‘OMW’s’ for short.  The following brief explanation is reproduced from Part 1:

The term ‘Objects of Intrinsic Moral Worth’ denotes objects, effects on which are considered relevant in assessing the morality of a proposed action.  Thus in the example of an assailant who accosts a man who is out walking his dog, and beats them both to death with a stick; the effects on the man, and (most probably) on the dog would be considered relevant to any assessment of the morality of  the assault.  However, it is most unlikely that the damage to the stick would, for its own sake, be considered relevant in any particular moral assessment of the action.  This situation could be described by saying that the man and his dog - but not the stick - were, in the particular moral theory under discussion, ‘Objects of Intrinsic Moral Worth’.

[viii] Conclusion 5 -5 : All patients diagnosed as PVS, should be treated as if they are conscious and can experience pain.

[ix] The prohibition on ‘absolute quality of life’ judgements advocated in Part 2 relates to persons.

See Conclusion 7 - 5 :There are at least two reasons why ‘absolute quality of life’ judgements should be rejected: they are unreliable and they are incompatible with the egalitarian principle that all persons be treated as equal.[ix]  Furthermore ‘absolute quality of life’ judgements often function as a mechanism of denial so that situations which are unacceptable to the decision-maker are not permitted to continue.

[x] i.e. a patient who had lost their personhood.

[xi] i.e. the wider society whose interests may be termed the ‘common good’; these wider social interests could be considered as flowing from ‘Social Justice’; thus, in judging whether an action ought to be performed it must be examined under the aspect of Charity and under the aspect of Justice (both in its individual and social expressions).  These ideas are developed in Chapter 9 and 10.

[xii] The development of euthanasia in pre-war Germany - which is briefly sketched in Appendix E - is of some assistance in considering the wider social implications of permitting assisted suicide.

[xiii] or a ‘minimally aware’ patient who might be expected to become lucid at some future stage.