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Ethics in Practice

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Peter, a 32 year old, suffered horrific injuries as the result of the collapse of a bridge over which he was driving his car. He has been classified as being in a persistent vegetative state for the past five years.

Although Peter’s brain stem is still functioning, his heart is beating and he can breathe spontaneously, he is dependent on oral feeding for the continuation of his life. The doctors in charge of his case have come to the decision that Peter’s life is no longer of value to him and have requested that they be allowed to withdraw his food supply. It is legal for doctors to withdraw medical support, however, feeding a patient is regarded as part of palliative care and not a medical treatment. Peter’s parents have taken the case to court in order to prevent his doctors from withdrawing his feeding tubes. What decision would you advise the judges to make in this case?

The debate over whether to withdraw Peter’s food supply in the above case arises from the conflicting values of his parents and his doctors. Peter’s perspective is central to evaluating the case; the withdrawal of his feeding tubes violates his right to life. The constraint of Peter’s role is that being in a persistent vegetative state, he is unable to exercise his autonomy and indicate what value he believes should be placed on his life.

As Peter is unable to express his judgement, and we don’t know if he has expressed an opinion prior to this event, his parents take on the role of representing his interests. His parents are required to use their knowledge of Peter’s values to decide his best interests1. Their decision that Peter’s life should be prolonged can be argued for using Utilitarianism, Deontology, and virtue ethics.

In a general sense, Utilitarianism

prevents the ending of human life if so doing fails to optimise the goods the position holds to be valuable. If one takes Peter’s loved ones to be the applicable society, and the valued goods to be continuation of hope, or prevention of grief, then such a moral Brock, Dan W., ‘Life-Sustaining Treatment and Euthanasia: Ethical Aspects’, in Stephen G. Post (ed.), Encyclopedia of Bioethics, 3rd ed. (New York: Macmillan Reference, 2004), Vol. 3, p. 1412  theory would prohibit the withdrawal of his feeding tubes. In terms of Aristotelian ethics, the determination to sustain Peter’s life entails virtues of courage, loyalty and caring, thus this moral theory can support his parents’ decision.

Morality as right acts and intentions can also support this decision. Deontology leads to a fundamental moral duty not to deliberately end an innocent human’s life, a duty to respect the intrinsic value of human life. This duty follows from Kant’s practical imperative that humans must always be treated as means in themselves, never as ends alone. The intrinsic value of human life is also supported by the concept that a right to life is the foundation of all other rights. Rights and duties are complementary within deontology as our being dutiful upholds the rights of others, and our rights result from others’ performance of their duty. Humans have a right not to be killed, as so doing denies them their future. Peter’s parents’ decision upholds their duty to respect the intrinsic value of human life, and upholds Peter’s right not to be killed. The stance the Peter’s parents take can be defended by all of the moral theories outlined, especially if we know that Peter is not in pain.

The position that Peter’s doctors have taken on can also be argued for through all of these moral theories. His doctors are able to draw on their experience as well as their knowledge and training to assess Peter’s case. Their perspective is in keeping with Aristotelian ethics as the virtues of judgement and resoluteness are employed. Importantly, his doctors use phronesis, practical wisdom, which is a central value in Aristotle’s account2. The perspective of Peter’s doctors may be related to deontology in that it involves a sense of duty, universalisabilty. However, Deontology is a much more effective framework for supporting Euthanasia when consent is given by the patient, as the individual’s right not to be killed could then be understood as waived.

In a teleological framework, Euthanasia can be defended as it brings an end to the pain and suffering of the patient, which is surely a meaningful consequence. It is Jonsen, Albert R. and Stephen Toulmin, ‘Theory and Practice’, in The Abuse of Casuistry: A History of Moral Reasoning (Berkeley: University of California Press, 1988), pp. 23-45.

Brock, Dan W., ‘Life-Sustaining Treatment and Euthanasia: Ethical Aspects’, in Stephen G. Post (ed.), Encyclopedia of Bioethics, 3rd ed. (New York: Macmillan Reference, 2004), unclear in Peter’s case whether or not he feels pain, and perhaps it is not possible to ascertain what someone in a persistent vegetative state is aware of. Utilitarianism demands Euthanasia in cases where it would produce the greatest balance of benefits over harms. It is entirely plausible for this to be the case with Peter. The ending of his life would free up resources which could be of benefit for other patients. He may be used as an organ donor which would again benefit other patients. The ending of his life may even ultimately benefit his parents, since by being forced to let go they will be forced to confront their grief. If these consequences hold as optimal, Peter’s doctors’ decision is supported by Utilitarianism.

The best possible ethical response to Peter’s case depends on what values are given most weight, which moral theory is accepted. His parents’ position is supported most strongly by deontology, whereas his doctors’ decision is more in keeping with Aristotelian ethics.

The moral framework I found most convincing is that proposed by Carol Gilligan whereby a care perspective exists in addition to the traditional justice perspective. The central concerns of an ethic of care are sensitivity to others needs, responsibility for taking care, and maintaining relationships. From a care perspective, relationships are organized in terms of attachment, as a network or web, whereas from a justice perspective relationships are organized in a hierarchy in order to look at equality. In a care perspective the relationship is the figure, the moral agent, whereas in a justice perspective the self is the moral agent who judges conflicting claims against a standard of equality4. The ultimate end of the care ethic is maintaining relationships.

The end of the justice model is personal liberty. Gilligan proposes that one can see a moral problem from one perspective initially, but when guided view it from the other perspective, however individuals generally have a preferred or dominant way of viewing a moral dilemma. Gilligan emphasizes that care and justice perspectives are not polar opposites, or mirror images, they are different ways of looking at the basic elements of moral judgment. The fact that they are not polar opposites, with one perspective a better or worse way of passing moral judgment is, according to Gilligan, what makes seeing both perspectives so difficult, the terms of one perspective do not define the terms of the other.

Gilligan’s theory is appropriate to consider here for two reasons. Firstly the other moral theories have been criticised within the Euthanasia debate for being overly calculative, inadequate to express the complexities involved in end of life decisions. Secondly, the care perspective contains important insights for this case as ultimately it seems less about Peter’s concerns in and of themselves, than it is an issue about Peter’s parents, and their connectedness with their son’s body. An ethic of care can account for this in way that other moral theories can’t. Through this theory it would seem morally wrong to forcefully remove Peter from his parents, yet it also seems unethical to allow his parents to define the remainder of their lives around the motionless form that remains of their son.

The best possible ethical response to this case is not to end Peter’s life against the will of his parents, nor is it to leave him dependent on a feeding tube indefinitely. Ideally a situation would be created where his parents made the decision to end Peter’s life. I would advise the judge to recommend counselling for his parents, to enable them to address their grief, and come to a place where they are able to let go of Peter’s physical form. When this occurs, the greatest balance of benefits over harms would clearly be to end Peter’s life, so this outcome would be demanded by utilitarianism. Peter’s doctors and parents would be demonstrating virtues of judgement, resoluteness, courage and caring. Their decision would be reached through phronesis, and thus supported by Aristotelian ethics5. His parents’ consent would waive Peter’s right not to be killed, and hence the ending of his life would not be in sharp contrast with the values of deontology. Peter’s parents’ relationship with his memory would be preserved, so achieving the ultimate end of an ethic of care. This decision would therefore satisfy the conditions of each moral theory examined. The ethical response I have given depends on the assumption that Peter’s life is no longer of intrinsic value to him, as claimed by his doctors. If it was known that Peter was aware of pain, then I would form an argument for ending his life regardless of his parents consent. If it could be shown that Peter was aware of what was going on around him, but was not in pain, this would again alter my decision. The implications of being aware but unable to respond would need to be considered.

The other particular given in the case, which initially seems to differentiate it from a general debate about euthanasia of incompetent patients, is that Peter is receiving palliative care rather than medical treatment. This affects whether his treatment is understood as ordinary or extraordinary, but this distinction doesn’t seem to affect whether the continuation or withdrawal of care is morally obligatory.

The decision I have advised in this case seems to be the best possible ethical response, but it is unknown whether it would be successful in practice. The response assumes that Peter’s parents are adamant that his palliative care continues because they feel connected to their son by his physical presence, and are enabled by the continuation of his life to foster hope. It is possible that his parents object to ending his life for other reasons, such as religious beliefs. If this were the case I still believe a strong attempt to convince Peter’s parents to consent must precede the involuntary ending of Peter’s life if such an action is to be ethically defensible.

Aristotle, selections from Nicomachean Ethics, in The Ethics of Aristotle: The Nicomachean Ethics, trans. J.A.K. Thomson. rev. Hugh Tredennick (Harmondsworth: Penguin Books, 1976)
Brock, Dan W., ‘Life-Sustaining Treatment and Euthanasia: Ethical Aspects’, in Stephen G. Post (ed.), Encyclopedia of Bioethics, 3rd ed. (New York: Macmillan Reference, 2004), Vol. 3, pp. 1410-20.

Doerflinger, Richard ‘Assisted Suicide: Pro-choice or Anti-life (Mercy, Murder & Morality: Perspectives on Euthanasia)’, The Hastings Center Report, Vol. 19, No. 1, 1989.
Gilligan, Carol, ‘Moral Orientation and Moral Development’, in Eva Feder Kittay and Diana T. Meyers, eds, Women and Moral Theory (Totowa, NJ: Rowman & Littlefield, 1987), pp. 19-32
Hinman, Lawrence M, ‘A Pluralistic Approach to Contemporary Moral Issues’, in Contemporary Moral Issues: Diversity and Consensus, 3rd ed. (Upper Saddle River, NJ: Person/Prentice Hall, 2006), pp. xiii-xxiii.

Jonsen, Albert R. and Stephen Toulmin, ‘Theory and Practice’, in The Abuse of Casuistry: A History of Moral Reasoning (Berkeley: University of California Press, 1988), pp. 23-45.
Norden, Margaret ‘”Whose Life is it Anyway?” A Study in Respect for Autonomy’, Journal of Medical Ethics, Vol. 21, 1995, 179-83.
Walker, Margaret Urban, ‘What does the Different Voice Say? Gilligan’s Women and Moral Philosophy’, in Moral Contexts (Lanham, MD: Rowman & Littlefield, 2003, pp. 57-69)

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