Ethical Issues at End of Life

Ethical Issues in End-of-Life Decisions: A Guide to Understanding Differences : Ethical Issues in End-of-Life Decisions: A Guide to Understanding Differences


An Exciting Timefor Ethics : An Exciting Time for Ethics New technologies Policy vacuums Ethical & legal quandaries


An Increasing Interest inEnd-of-life Issues : An Increasing Interest in End-of-life Issues The upcoming Bill Moyers series on dying; starts Sunday evening, Sept. 10, 2000. Upcoming JAMA issue on End-of-life decisions


Goals of Today’s Talk : Goals of Today’s Talk Provide a framework for understanding why and how intelligent people of good will can disagree so fundamentally about end-of-life decisions. Better understand the positions of other people, including patients Better understand our own intuitions


Two Models : Two Models A utilitarian model, which emphasizes consequences A Kantian model, which emphasizes autonomy, rights, and respect


The Utilitarian Model : The Utilitarian Model Goes back at least to John Stuart Mill (1806-73) The greatest good for the greatest number


Main Tenets : Main Tenets Morality is a matter of consequences We must count the consequences for everyone Everyone’s suffering counts equally We must always act in a way that produces the greatest overall good consequences and least overall bad consequences.


The Calculus : The Calculus Morality becomes a matter of mathematics, calculating and weighing consequences Key insight: consequences matter The dream: bring certainty to ethics


How much care should be given at the end of life? : How much care should be given at the end of life? Health care providers are increasingly concerned, not just about how much money is spent on patients, but about how effectively it is spent. Disproportionate amount of money spent in final months of life. 40 percent of Medicare dollars cover care for people in the last month. Nearly one third of terminally ill patients with insurance used up most or all of their savings to cover uninsured medical expenses such as home care. Concept of medical futility is utilitarian in character.


What is a good death? : What is a good death? Jeremy Bentham. Hedonistic utilitarians: a good death is a painless death. Eudaimonistic utilitarians: a good death is a happy death. John Stuart Mill


Understanding Bizarre Suggestions : Understanding Bizarre Suggestions All of the following make sense if we think of end-of-life decisions solely in terms of reducing painful consequences: Passive euthanasia sometimes worse than active euthanasia—James Rachels “It’s over, Debbie”—just end the suffering A duty to die


The Kantian Model : The Kantian Model Central insight: people cannot be treated like mere things. Key notions: Autonomy & Dignity Respect Rights


Autonomy & Respect : Autonomy & Respect Kant felt that human beings were distinctive: they have the ability to reason and the ability to decide on the basis of that reasoning. Autonomy = freedom + reason Autonomy for Kant is the ability to impose reason freely on oneself.


Treating People as Mere Means : Treating People as Mere Means The Tuskegee Syphilis Experiments More than four hundred African American men infected with syphilis went untreated for four decades in a project the government called the Tuskegee Study of Untreated Syphilis in the Negro Male. Continued until 1972


Protecting Autonomy : Protecting Autonomy Advanced Directives are designed to protect the autonomy of patients They derive directly from a Kantian view of what is morally important.


Autonomy: Who Decides : Autonomy: Who Decides Kantians emphasize the importance of a patient’s right to decide Utilitarians look only at consequences In cases such as the Siamese twins, they see radically different worlds.


From Autonomy to Rights : From Autonomy to Rights Because human beings have the ability to make up their own minds in accord with the dictates of reason, they have certain rights. If someone has a right, we have a correlatively duty to respect that right. Rights Duties


Types of Rights : Types of Rights Two types of rights Negative: imposes duties of non-interference on others Positive: imposes duties of assistance on others Health care (including end-of-life care) as a right: Negative right. Widespread agreement on this. Positive right. Much disagreement. Do people have a right to health care even when they can’t pay? On whose shoulders does the duty fall?


Conclusion : Conclusion Many of the ethical disagreements about end-of-life decisions can be seen as resulting from differing ethical frameworks, esp. Kantian vs. utilitarian. Use these models to understand where you stand, where your patients stand, and where your organization stands in regard to end-of-life issues.


A Quick SurveyQuestion #1 : A Quick Survey Question #1 First, in regard to your own position. How many of you identify primarily with utilitarian ethical thinking? How many of you find yourselves identifying primarily with Kant’s ethical standpoint? How many of you identify with a moral perspective that you feel is neither utilitarian nor Kantian?


A Quick SurveyQuestion #2 : A Quick Survey Question #2 Now think about your patients’ moral orientations, insofar as you know what these are. How many of you think your patients see their own moral decisions about end of life issues primarily in utilitarian terms? How many of you think your patients see their own moral decisions about end of life issues primarily in Kantian terms or autonomy and respect? How many of you think your patients see their own moral decisions about end of life issues primarily in terms that are neither Kantian nor utilitarian?


A Quick Survey Question #3 : A Quick Survey Question #3 Third, I’d be interested in your perceptions of your organization’s moral orientation. How many of you think Sharp-Rees Steely sees decisions about end of life issues primarily in utilitarian terms? How many of you think Sharp-Rees Steely sees decisions about end of life issues primarily in Kantian terms? How many of you think Sharp-Rees Steely sees decisions about end of life issues primarily in terms that are neither Kantian nor utilitarian?


A Quick Survey:Overview : A Quick Survey: Overview


A Quick Survey: Results : A Quick Survey: Results Finally, I’d be interested in discrepancies. How many had a straight line across—all utilitarian or all Kantian? How many had a difference in moral orientations between themselves and their patients? How many had a difference in moral orientations between themselves and their organization? How many had a difference in moral orientations between their patients and their organization?


Appendix 1From whole to parts : Appendix 1 From whole to parts Person Soul Mind Body Priest, Minister Rabbi Doctor Psychologist ENT Ophthalmologist Urologist Oncologist Psychiatrist


Appendix 2Stakeholders in the Decision-making Process : Appendix 2 Stakeholders in the Decision-making Process End-of-life decisions involve more than the patient and the physician. Patient Physician Patient’s Family Insurer/ HMO


Web Resources : Web Resources


Web Resources,2 : Web Resources, 2 Before I Die With Bill Moyers http://www.pbs.org/wnet/bid/


Web Resources, 3 : Web Resources, 3 The End of Life: Explaining Death in America http://www.npr.org/programs/death/


This presentation : This presentation This presentation will be available at: http://ethics.acusd.edu/presentations/sharp/