Beneficence, Nonmaleficence, and Technological Progress


190.1

190.2

Joseph D. Bronzino 190.3

Trinity College/Biomedical Engineering Alliance for Connecticut (BEACON)

Introduction

Defining Death: A Moral Dilemma Posed by

Medical Technology

Euthanasia

Active Versus Passive Euthanasia • Involuntary and Non Voluntary Euthanasia • Should Voluntary Euthanasia be Legalized?

Introduction

Two moral norms have remained relatively constant across the various moral codes and oaths that have been formulated for health-care deliverers since the beginnings of Western medicine in classical Greek civilization, namely beneficence—the provision of benefits—and nonmaleficence—the avoidance of doing harm. These norms are traced back to a body of writings from classical antiquity known as the Hippocratic Corpus. Although these writings are associated with the name of Hippocrates, the acknowl­edged founder of Western medicine, medical historians remain uncertain whether any, including the Hippocratic Oath, were actually his work. Although portions of the Corpus are believed to have been authored during the sixth century BC, other portions are believed to have been written as late as the beginning of the Christian Era. Medical historians agree, though, that many of the specific moral directives of the Corpus represent neither the actual practices nor the moral ideals of the majority of physicians of ancient Greece and Rome.

Nonetheless, the general injunction, “As to disease, make a habit of two things—to help or, at least, to do no harm," was accepted as a fundamental medical ethical norm by at least some ancient physicians. With the decline of Hellenistic civilization and the rise of Christianity, beneficence and nonmaleficence became increasingly accepted as the fundamental principles of morally sound medical practice. Although beneficence and nomaleficence were regarded merely as concomitant to the craft of medicine in classical Greece and Rome, the emphasis upon compassion and the brotherhood of humankind, central to Christianity, increasingly made these norms the only acceptable motives for medical practice. Even today the provision of benefits and the avoidance of doing harm are stressed just as much in virtually all contemporary Western codes of conduct for health professionals as they were in the oaths and codes that guided the health-care providers of past centuries.

Traditionally, the ethics of medical care have given greater prominence to nomaleficence than to beneficence. This priority was grounded in the fact that, historically, medicine’s capacity to do harm far exceeded its capacity to protect and restore health. Providers of health care possessed many treatments
that posed clear and genuine risks to patients but that offered little prospect of benefit. Truly effective therapies were all too rare. In this context, it is surely rational to give substantially higher priority to avoiding harm than to providing benefits.

The advent of modern science changed matters dramatically. Knowledge acquired in laboratories, tested in clinics, and verified by statistical methods has increasingly dictated the practices of medicine. This ongoing alliance between medicine and science became a critical source of the plethora of technol­ogies that now pervades medical care. The impressive increases in therapeutic, preventive, and rehabil­itative capabilities that these technologies have provided have pushed beneficence to the forefront of medical morality. Some have even gone so far as to hold that the old medical ethic of “Above all, do no harm” should be superseded by the new ethic that “The patient deserves the best.” However, the rapid advances in medical technology capabilities have also produced great uncertainty as to what is most beneficial or least harmful for the patient. In other words, along with increases in ability to be beneficent, medicine’s technology has generated much debate about what actually counts as beneficent or nonma — leficent treatment. To illustrate this point, let us turn to several specific moral issues posed by the use of medical technology (Bronzino, 1992; 1999).

Defining Death: A Moral Dilemma Posed by Medical Technology

Supportive and resuscitative devices, such as the respirator, found in the typical modern intensive care unit provide a useful starting point for illustrating how technology has rendered medical morality more complex and problematic. Devices of this kind allow clinicians to sustain respiration and circulation in patients who have suffered massive brain damage and total permanent loss of brain function. These technologies force us to ask: precisely when does a human life end? When is a human being indeed dead? This is not the straightforward factual matter it may appear to be. All of the relevant facts may show that the patient’s brain has suffered injury grave enough to destroy its functioning forever. The facts may show that such an individual’s circulation and respiration would permanently cease without artificial support. Yet these facts do not determine whether treating such an individual as a corpse is morally appropriate. To know this, it is necessary to know or perhaps to decide on those features of living persons that are essential to their status as “living persons.” It is necessary to know or decide which human qualities, if irreparably lost, make an individual identical in all morally relevant respects to a corpse. Once those qualities have been specified, deciding whether total and irreparable loss of brain function constitutes death becomes a straightforward factual matter. Then, it would simply have to be determined if such loss itself deprives the individual of those qualities. If it does, the individual is morally identical to a corpse. If not, then the individual must be regarded and treated as a living person.

The traditional criterion of death has been irreparable cessation of heart beat, respiration, and blood pressure. This criterion would have been quickly met by anyone suffering massive trauma to the brain prior to the development of modem supportive technology. Such technology allows indefinite artificial maintenance of circulation and respiration and, thus, forestalls what once was an inevitable consequence of severe brain injury. The existence and use of such technology therefore challenges the traditional criterion of death and forces us to consider whether continued respiration and circulation are in them­selves sufficient to distinguish a living individual from a corpse. Indeed, total and irreparable loss of brain function, referred to as “brainstem death,” “whole brain death,” and, simply, “brain death,” has been widely accepted as the legal standard for death. By this standard, an individual in a state of brain death is legally indistinguishable from a corpse and may be legally treated as one even though respiratory and circulatory functions may be sustained through the intervention of technology. Many take this legal standard to be the morally appropriate one, noting that once destruction of the brain stem has occurred, the brain cannot function at all, and the body’s regulatory mechanisms will fail unless artificially sustained. Thus mechanical sustenance of an individual in a state of brain death is merely postponement of the inevitable and sustains nothing of the personality, character, or consciousness of the individual. It is merely the mechanical intervention that differentiates such an individual from a corpse and a mechan­ically ventilated corpse is a corpse nonetheless.

Even with a consensus that brainstem death is death and thus that an individual in such a state is indeed a corpse, hard cases remain. Consider the case of an individual in a persistent vegetative state, the condition known as “neocortical death.” Although severe brain injury has been suffered, enough brain function remains to make mechanical sustenance of respiration and circulation unnecessary. In a persistent vegetative state, an individual exhibits no purposeful response to external stimuli and no evidence of self-awareness. The eyes may open periodically and the individual may exhibit sleep-wake cycles. Some patients even yawn, make chewing motions, or swallow spontaneously. Unlike the complete unresponsiveness of individuals in a state of brainstem death, a variety of simple and complex responses can be elicited from an individual in a persistent vegetative state. Nonetheless, the chances that such an individual will regain consciousness virtually do not exist. Artificial feeding, kidney dialysis, and the like make it possible to sustain an individual in a state of neocortical death for decades. This sort of condition and the issues it raises were exemplified by the famous case of Karen Ann Quinlan. James Rachels (1986) provided the following description of the situation created by Quinlan’s condition:

In April 1975, this young woman ceased breathing for at least two 15-minute periods, for reasons that were never made clear. As a result, she suffered severe brain damage, and, in the words of the attending physicians, was reduced to a “chronic vegetative state” in which she “no longer had any cognitive function.” Accepting the doctors’ judgment that there was no hope of recovery, her parents sought permission from the courts to disconnect the respirator that was keeping her alive in the intensive care unit of a New Jersey hospital.

The trial court, and then the Supreme Court of New Jersey, agreed that Karen’s respirator could be removed. So it was disconnected. However, the nurse in charge of her care in the Catholic hospital opposed this decision and, anticipating it, had begun to wean her from the respirator so that by the time it was disconnected she could remain alive without it. So Karen did not die. Karen remained alive for ten additional years. In June 1985, she finally died of acute pneumonia. Antibiotics, which would have fought the pneumonia, were not given.

If brainstem death is death, is neocortical death also death? Again, the issue is not a straightforward factual matter. For, it too, is a matter of specifying which features of living individuals distinguish them from corpses and so make treatment of them as corpses morally impermissible. Irreparable cessation of respiration and circulation, the classical criterion for death, would entail that an individual in a persistent vegetative state is not a corpse and so, morally speaking, must not be treated as one. The brainstern death criterion for death would also entail that a person in a state of neocortical death is not yet a corpse. On this criterion, what is crucial is that brain damage be severe enough to cause failure of the body’s regulatory mechanisms.

Is an individual in a state of neocortical death any less in possession of the characteristics that distinguish the living from cadavers than one whose respiration and circulation are mechanically main­tained? Of course, it is a matter of what the relevant characteristics are, and it is a matter that society must decide. It is not one that can be settled by greater medical information or more powerful medical devices. Until society decides, it will not be clear what would count as beneficent or nonmaleficent treatment of an individual in a state of neocortical death.

190.3 Euthanasia

A long-standing issue in medical ethics, which has been made more pressing by medical technology, is euthanasia, the deliberate termination of an individual’s life for the individual’s own good. Is such an act ever a permissible use of medical resources? Consider an individual in a persistent vegetative state. On the assumption that such a state is not death, withdrawing life support would be a deliberate termination of a human life. Here a critical issue is whether the quality of a human life can be so low or so great a liability to the individual that deliberately taking action to hasten death or at least not to postpone death is morally defensible. Can the quality of a human life be so low that the value of extending its quantity is totally negated? If so, then Western medicine’s traditional commitment to providing benefits and avoiding harm would seem to make cessation of life support a moral requirement in such a case.

Consider the following hypothetical version of the kind of case that actually confronts contemporary patients, their families, health-care workers, and society as a whole. Suppose a middle-aged man suffers a brain hemorrhage and loses consciousness as a result of a ruptured aneurysm. Suppose that he never regains consciousness and is hospitalized in a state of neocortical death, a chronic vegetative state. He is maintained by a surgically implanted gastronomy tube that drips liquid nourishment from a plastic bag directly into his stomach. The care of this individual takes seven and one-half hours of nursing time daily and includes

Shaving, (2) oral hygiene, (3) grooming, (4) attending to his bowels and bladder, and so forth.

Suppose further that his wife undertakes legal action to force his care givers to end all medical treatment, including nutrition and hydration, so that complete bodily death of her husband will occur. She presents a preponderance of evidence to the court to show that her husband would have wanted this result in these circumstances.

The central moral issue raised by this sort of case is whether the quality of the individual’s life is sufficiently compromised by neocortical death to make intentioned termination of that life morally permissible. While alive, he made it clear to both family and friends that he would prefer to be allowed to die rather than be mechanically maintained in a condition of irretrievable loss of consciousness. Deciding whether the judgment in such a case should be allowed requires deciding which capacities and qualities make life worth living, which qualities are sufficient to endow it with value worth sustaining, and whether their absence justifies deliberate termination of a life, at least when this would be the wish of the individual in question. Without this decision, the traditional norms of medical ethics, beneficence and nonmaleficence, provide no guidance. Without this decision, it cannot be determined whether termination of life support is a benefit or a harm to the patient.

An even more difficult type of case was provided by the case of Elizabeth Bouvia. Bouvia, who had been a lifelong quadriplegic sufferer of cerebral palsy, was often in pain, completely dependent upon others, and spent all of her time bedridden. Bouvia, after deciding that she did not wish to continue such a life, entered Riverside General Hospital in California. She desired to be kept comfortable while starving to death. Although she remained adamant during her hospitalization, Bouvia’s requests were denied by hospital officials with the legal sanction of the courts.

Many who might believe that neocortical death renders the quality of life sufficiently low to justify termination of life support, especially when this agrees with the individual’s desires, would not arrive at this conclusion in a case like Bouvia’s. Whereas neocortical death completely destroys consciousness and makes purposive interaction with the individual’s environment impossible, Bouvia was fully aware and mentally alert. She had previously been married and had even acquired a college education. Televised interviews with her portrayed a very intelligent person who had great skill in presenting persuasive arguments to support her wish not to have her life continued by artificial means of nutrition. Nonetheless, she judged her life to be of such low quality that she should be allowed to choose to deliberately starve to death. Before the existence of life support technology, maintenance of her life against her will might not have been possible at all and at least would have been far more difficult.

Should Elizabeth Bouvia’s judgment have been accepted? Her case is more difficult than the care of a patient in a chronic vegetative state because, unlike such an individual, she was able to engage in meaningful interaction with her environment. Regarding an individual who cannot speak or otherwise meaningfully interact with others as nothing more than living matter, as a “human vegetable,” is not especially difficult. Seeing Bouvia this way is not easy. Her awareness, intelligence, mental acuity, and ability to interact with others means that although her life is one of discomfort, indignity, and complete dependence, she is not a mere “human vegetable.”

Despite the differences between Bouvia’s situation and that of someone in a state of neocortical death, the same issue is posed. Can the quality of an individual’s life be so low that deliberate termination is morally justifiable? How that question is answered is a matter of what level of quality of life, if any, is taken to be sufficiently low to justify deliberately acting to end it or deliberately failing to extend it. If there is such a level, the conclusion that it is not always beneficent or even nonmaleficent to use life-support technology must be accepted.

Another important issue here is respect for individual autonomy. For the cases of Bouvia and the hypothetical instance of neocortical death discussed above, both concern voluntary euthanasia, that is, euthanasia voluntarily requested by the patient. A long-standing commitment, vigorously defended by various schools of thought in Western moral philosophy, is the notion that competent adults should be free to conduct their lives as they please as long as they do not impose undeserved harm on others. Does this commitment entail a right to die? Some clearly believe that it does. If one owns anything at all, surely one owns one’s life. In the two cases discussed above, neither individual sought to impose undeserved harm on anyone else, nor would satisfaction of their wish to die do so. What justification can there be then for not allowing their desires to be fulfilled?

One plausible answer is based upon the very respect of individual autonomy at issue here. A necessary condition, in some views, of respect for autonomy is the willingness to take whatever measures are necessary to protect it, including measures that restrict autonomy. An autonomy-respecting reason offered against laws that prevent even competent adults from voluntarily entering lifelong slavery is that such an exercise of autonomy is self-defeating and has the consequence of undermining autonomy altogether. By the same token, an individual who acts to end his own life thereby exercises his autonomy in a manner that places it in jeopardy of permanent loss. Many would regard this as justification for using the coercive force of the law to prevent suicide. This line of thought does not fit the case of an individual in a persistent vegetative state because his/her autonomy has been destroyed by the circumstances that rendered him/her neocortically dead. It does fit Bouvia’s case though. Her actions indicate that she is fully competent and her efforts to use medical care to prevent the otherwise inevitable pain of starvation is itself an exercise of her autonomy. Yet, if allowed to succeed, those very efforts would destroy her autonomy as they destroy her. On this reasoning, her case is a perfect instance of limitation of autonomy being justified by respect for autonomy and of one where, even against the wishes of a competent patient, the life-saving power of medical technology should be used.

Active Versus Passive Euthanasia

Discussions of the morality of euthanasia often distinguish active from passive euthanasia in light of the distinction made between killing a person and letting a person die, a distinction that rests upon the difference between an act of commission and an act of omission. When failure to take steps that could effectively forestall death results in an individual’s demise, the resultant death is an act of omission and a case of letting a person die. When a death is the result of doing something to hasten the end of a person’s life (giving a lethal injection, for example), that death is caused by an act of commission and is a case of killing a person. When a person is allowed to die, death is a result of an act of omission, and the motive is the person’s own good, the omission is an instance of passive euthanasia. When a person is killed, death is the result of an act of commission, and the motive is the person’s own good, the commission is an instance of active euthanasia.

Does the difference between passive and active euthanasia, which reduces to a difference in how death comes about, make any moral difference? It does in the view of the American Medical Association. In a statement adopted on December 4, 1973, the House of Delegates of the American Medical Association asserted the following (Rachels, 1978):

The intentional termination of the life of one human being by another—mercy killing—is contrary to that for which the medical profession stands and is contrary to the policy of the American Medical Association (AMA).

The cessation of extraordinary means to prolong the life of the body where there is irrefutable evidence that biological death is imminent is the decision of the patient and immediate family. The advice of the physician would be freely available to the patient and immediate family.

In response to this position, Rachels (1978) answered with the following:

The AMA policy statement isolates the crucial issue very well, the crucial issue is “intentional termi­nation of the life of one human being by another.” But after identifying this issue and forbidding “mercy killing,” the statement goes on to deny that the cessation of treatment is the intentional termination of a life. This is where the mistake comes in, for what is the cessation of treatment in those circumstances (where the intention is to release the patient from continued suffering), if it is not “the intentional termination of the life of one human being by another?”

As Rachels correctly argues, when steps that could keep an individual alive are omitted for the person’s own good, this omission is as much the intentional termination of life as taking active measures to cause death. Not placing a patient on a respirator due to a desire not to prolong suffering is an act intended to end life as much as the administration of a lethal injection. In many instances the main difference between the two cases is that the latter would release the individual from his pain and suffering more quickly than the former. Dying can take time and involve considerable pain even if nothing is done to prolong life. Active killing can be done in a manner that causes death painlessly and instantly. This difference certainly does not render killing, in this context, morally worse than letting a person die. Insofar as the motivation is merciful (as it must be if the case is to be a genuine instance of euthanasia) because the individual is released more quickly from a life that is disvalued than otherwise, the difference between killing and letting one die may provide support for active euthanasia. According to Rachels (1978), the common rejoinder to this argument is the following:

The important difference between active and passive euthanasia is that in passive euthanasia the doctor does not do anything to bring about the patient’s death. The doctor does nothing and the patient dies of whatever ills already afflict him. In active euthanasia, however, the doctor does something to bring about the patient’s death: he kills the person. The doctor who gives the patient with cancer a lethal injection has himself caused his patient’s death; whereas if he merely ceases treatment, the cancer is the cause of death.

According to this rejoinder, in active euthanasia someone must do something to bring about the patient’s death, and in passive euthanasia the patient’s death is caused by illness rather than by anyone’s conduct. Surely this is mistaken. Suppose a physician deliberately decides not to treat a patient who has a routinely curable ailment and the patient dies. Suppose further that the physician were to attempt to exonerate himself by saying, “I did nothing. The patient’s death was the result of illness. I was not the cause of death.” Under current legal and moral norms, such a response would have no credibility. As Rachels (1978) notes, “it would be no defense at all for him to insist that he didn’t do anything. He would have done something very serious indeed, for he let his patient die.”

The physician would be blameworthy for the patient’s death as surely as if he had actively killed him. If causing death is justifiable under a given set of circumstances, whether it is done by allowing death to occur or by actively causing death is morally irrelevant. If causing someone to die is not justifiable under a given set of circumstances, whether it is done by allowing death to occur or by actively causing death is also morally irrelevant. Accordingly, if voluntary passive euthanasia is morally justifiable in the light of the duty of beneficence, so is voluntary active euthanasia. Indeed, given that the benefit to be achieved is more quickly realized by means of active euthanasia, it may be preferable to passive euthanasia in some cases.

Involuntary and Non-Voluntary Euthanasia

An act of euthanasia is involuntary if it hastens the individual’s death for his own good but against his wishes. To take such a course would be to destroy a life that is valued by its possessor. Therefore, it is no different in any morally relevant way from unjustifiable homicide. There are only two legitimate reasons for hastening an innocent person’s death against his will: self-defense and saving the lives of a larger number of other innocent persons. Involuntary euthanasia does not fit either of these justifications. By definition, it is done for the good of the person who is euthanized and for self-defense or saving innocent others. No act that qualifies as involuntary euthanasia can be morally justifiable.

Hastening a person’s death for his own good is an instance of non-voluntary euthanasia when the individual is incapable of agreeing or disagreeing. Suppose it is clear that a particular person is sufficiently self-conscious to be regarded a person but cannot make his wishes known. Suppose also that he is suffering from the kind of ailment that, in the eyes of many persons, makes one’s life unendurable. Would hastening his death be permissible? It would be if there were substantial evidence that he has given prior consent. This person may have told friends and relatives that under certain circumstances efforts to prolong his life should not be undertaken or continued. He might have recorded his wishes in the form of a Living Will (below) or on audio — or videotape. Where this kind of substantial evidence of prior consent exists, the decision to hasten death would be morally justified. A case of this scenario would be virtually a case of voluntary euthanasia.

But what about an instance in which such evidence is not available? Suppose the person at issue has never had the capacity for competent consent or dissent from decisions concerning his life. It simply cannot be known what value the individual would place on his life in his present condition of illness. What should be done is a matter of what is taken to be the greater evil—mistakenly ending the life of an innocent person for whom that life has value or mistakenly forcing him to endure a life that he radically disvalues.

To My Family, My Physician, My Clergyman, and My Lawyer:

If the time comes when I can no longer take part in decisions about my own future, let this statement stand as testament of my wishes: If there is no reasonable expectation of my recovery from physical or mental disability,

I, , request that I be allowed to die and not be kept alive by artificial means

Or heroic measures. Death is as much a reality as birth, growth, maturity, and old age—it is the one certainty. I do not fear death as much as I fear the indignity of deterioration, dependence, and hopeless pain. I ask that drugs be mercifully administered to me for the terminal suffering even if they hasten the moment of death.

This request is made after careful consideration. Although this document is not legally binding, you who care for me will, I hope, feel morally bound to follow its mandate. I recognize that it places a heavy burden of responsibility upon you, and it is with the intention of sharing that responsibility and of mitigating any feelings of guilt that this statement is made.

Signed:

Date:

Witnessed by:

Living Will statutes have been passed in at least 35 states and the District of Columbia. For a Living Will to be a legally binding document, the person signing it must be of sound mind at the time the will is made and shown not to have altered his opinion in the interim between the signing and his illness. The witnesses must not be able to benefit from the individual’s death.

Should Voluntary Euthanasia be Legalized?

The recent actions of Dr. Kavorkian have raised the question: “Should voluntary euthanasia be legalized?” Some argue that even if voluntary euthanasia is morally justifiable, it should be prohibited by social policy nonetheless. According to this position, the problem with voluntary euthanasia is its impact on society as a whole. In other words, the overall disutility of allowing voluntary euthanasia outweighs the good it could do for its beneficiaries. The central moral concern is that legalized euthanasia would eventually erode respect for human life and ultimately become a policy under which “socially undesirable” persons would have their deaths hastened (by omission or commission). The experience of Nazi Germany is often cited in support of this fear. What began there as a policy of euthanasia soon became one of eliminating individuals deemed racially inferior or otherwise undesirable. The worry, of course, is that what happened there can happen here as well. If social policy encompasses efforts to hasten the deaths of people, respect for human life in general is eroded and all sorts of abuses become socially acceptable, or so the argument goes.

No one can provide an absolute guarantee that the experience of Nazi Germany would not be repeated, but there is reason to believe that its likelihood is negligible. The medical moral duty of beneficence justifies only voluntary euthanasia. It justifies hastening an individual’s death only for the individual’s benefit and only with the individual’s consent. To kill or refuse to save people judged socially undesirable is not to engage in euthanasia at all and violates the medical moral duty of nomaleficence. As long as only voluntary euthanasia is legalized, and it is clear that involuntary euthanasia is not and should never be, no degeneration of the policy need occur. Furthermore, such degeneration is not likely to occur if the beneficent nature of voluntary euthanasia is clearly distinguished from the maleficent nature of involuntary euthanasia and any policy of exterminating the socially undesirable. Euthanasia decisions must be scrutinized carefully and regulated strictly to ensure that only voluntary cases occur, and severe penalties must be established to deter abuse.

References

Bronzino, J. D. Chapter 10 Medical and Ethical Issues in Clinical Engineering Practice. In: Management of Medical Technology. Butterworth, 1992.

Bronzino, J. D. Chapter 20 Moral and Ethical Issues Associated with Medical Technology. In: Introduction to Biomedical Engineering. Academic Press, 1999.

Rachels, J. “Active and Passive Euthanasia,” In: Moral Problems, 3rd ed., Rachels, J., (Ed.), Harper and Row, New York, 1978.

Rachels, J. Ethics at the End of Life: Euthanasia and Morality, Oxford University Press, Oxford, 1986.

Further Information

Daniels, N. Just Health Care. Cambridge University Press, Cambridge, 1987.

Dubler, N. N. and Nimmons, D. Ethics on Call. Harmony Books, New York, 1992.

Jonsen, A. R. The New Medicine and the Old Ethics. Harvard University Press, Cambridge, MA, 1990. Murphy, J. and Coleman, J. The Philosophy of Law, Rowman and Allenheld, 1984.

>., Saha, P. S. “Ethical Issues of Animal and Human Experimentation in the Development of Medical Dev omedical Engineering Handbook: Second Edition.

;eph D. Bronzino

Laton: CRC Press LLC, 2000

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