HLTH 380 Week 10 (Death and Dying) - PDF

WEEK 10 - DEATH AND DYING Guest lecture: https://learn.uwaterloo.ca/content/enforced/1054906-GSJ380_HLTH380_eneiter m_1249/HLTH%20380%20Nov%202024%20Guest%20lecture%20by%20Karley %20%26%20Amanda%20-%20MAiD%20%26%20Suicide%20%20-%20%20Rea d-Only.pdf?isCourseFile=true&ou=1054906...

WEEK 10 - DEATH AND DYING Guest lecture: https://learn.uwaterloo.ca/content/enforced/1054906-GSJ380_HLTH380_eneiter m_1249/HLTH%20380%20Nov%202024%20Guest%20lecture%20by%20Karley %20%26%20Amanda%20-%20MAiD%20%26%20Suicide%20%20-%20%20Rea d-Only.pdf?isCourseFile=true&ou=1054906 Here’s a summary of the key points from the lecture on Medical Assistance in Dying (MAiD) and Suicide: 1. Overview and Historical Context Introduction to MAiD: Defined as a legal process in Canada allowing eligible individuals to seek medically assisted death. Legislative Milestones: ○ Bill C-14 (2016): Introduced MAiD in Canada, specifying eligibility and safeguard criteria. ○ Bill C-7 (2021): Expanded eligibility and revised safeguards, especially for cases where natural death is not foreseeable. 2. Eligibility Criteria Basic Requirements: ○ Must be eligible for health care funding in Canada. ○ 18 years or older and capable of making informed health decisions. ○ Have a grievous and irremediable medical condition. ○ Must make a voluntary request and provide informed consent. Medical Condition Specifications: ○ Must involve a serious, incurable illness causing intolerable suffering that cannot be relieved by other means acceptable to the patient. 3. Safeguards in Bill C-7 Track 1 (Natural Death Foreseeable): ○ Documentation, multiple assessments by independent professionals, and confirmation of understanding and consent. Track 2 (Natural Death NOT Foreseeable): ○ Includes all Track 1 safeguards plus additional measures like expert consultation and a mandatory 90-day reflection period. 4. Current Data and Trends (2022)  MAiD represented 4.1% of all deaths in Canada, with the majority occurring at private residences, hospitals, and palliative care facilities. Primary reasons cited included loss of meaningful activities, inability to perform daily activities, and inadequate pain control. 5. MAiD & Mental Health The Canadian Mental Health Association (CMHA) argues mental illnesses, though potentially unbearable, are not considered “irremediable” due to possibilities for recovery. The CMHA supports that people with mental health issues should be provided with resources to live, rather than seeking MAiD. 6. Comparison: MAiD vs. Suicide Ethical Considerations: Differentiated based on perspectives from libertarian, deontological, utilitarian, and virtue ethics frameworks. ○ Utilitarian: pain of watching someone suffer is worse than helping them dying ○ Virtue ethics: Discussion Prompts: Students encouraged to explore ethical differences and consider stances from various philosophical perspectives. 7. Support and Resources Campus counseling and crisis support options were highlighted, emphasizing that help is available for students and the public. These points cover the legislative background, ethical considerations, mental health perspectives, and available support systems. Let me know if you need further detail on any specific section! Lecture - death and dying This week: Death in historical and philosophical perspectives The changing meaning of death Definitions of death The status of brain-dead patients MAID, killing and letting die What is death? Social ○ What is acceptable to deal with grief? ○ Hope we celebrate that person? ○ Very by rituals and traditions Physiological religious ○ Unlike science ○ Provides us with some answers about what happens after death ○ Humanity cant answer some questions Religion and philosophy Plato: ○ Immortality of the soul ○ Reincarnation (human, animal) Christianity ○ Immortality They accepted this from plato ○ Transformation Division between body and soul Dualism started to emerge ○ Anthropocentrism Humans are the only ones who possess the soul and can transform that soul Differentiated this from other religions More centrally focused on individual humans as processor of the soul Philosopher started to challenge what happens to the soul David Hume ○ Scientists started to focus on the after life ○ Came to challenge afterlife Immanuel Kant ○ Is scientifically an afterlife ○ But consider other alternatives ○ In the minority ○ Humans arent that different from any other animal on the planet ?? Charles Darwin Sample question  Which of the following philosophers believed in the immortality of the soul? (Many of them didnt ) (a) Kant (b) Bentham (c) Darwin (d) Hume The changing meaning of death Removal of death from public domain ○ The majority of death happen after terminal illness ○ Were good at taking care of acute diseases ○ Removal of death from public domain. It used to be more prevalent ○ Exposure to seeing people die around you: we were more in tune with dealing with death ○ Now, majority happens in the hospital so others are not exposed Quest for immortality ○ More attempts at living longer Brian Turner (2009) Can we live forever? ○ Change in the type of disease Acute to chronic ○ Palliative care Shaped our vision and experience of death We save people and forget the ability of trying palliative care Give people some space to breath and let them acknowledge theyre dying ○ Belief in medicine ○ Loss of the “moment of death” Growing efforts of wanting to live forever Took away our ability to face death Think, pair, share What are the moral implications of this transition? What should we do now, when we have technology to keep people alive using machines? At what point should we stop the treatment of the brain-dead patients? At what point should the treatment be considered futile? Who decides when the treatment is futile? When is a person dead? Definition of death  Heart and lung functioning ○ Legally defined as dead: profound announcement of death ○ In old times, putting the mirror on the person to see if theyre alive or not, once stethoscope was installed, would apply that tool 1960 developments ○ Mechanical respirator Arififically have their heart and lungs pumping Can see someone is alive eventhough they cant function on their own Heart is beating, so can you classify as dead? ○ Organ transplantation Once we started experimenting, we were better of recurring organs from people who just died Easier to harvest organs from someone who just died rather than on ventilator Medical ethics: when you come tothe person who is still alive and you take their body parts, youre doing surgery on alive person (technically) Need to revise the definition of death 1968 harvard medical school Committee ○ “Whole brain” formulation Irreversible cessation of circulatory or respiratory functions or Heart and lung cant be functioning Irreversible cessation of all functions of the entire brain, including the brain stem The definition of death has been modified to enable us to define someone as clinically dead How brain-dead person can be considered dead The status of the brain-dead person Is the person alive or dead? ○ If a brain dead person can be considered dead…. Hans jonas ○ Once we know that this is cadaver, there is no logical reason to deny its use for any purpose ○ Is it ethical of us to use the body? ○ Once we say brain dead, it becomes a dead body, and there is no reason for us to deny the body for any purpose ○ If person is brain dead, keep on ventilator and can still use the body, for example, medical students to do work on  ○ Nothing morally wrong with using this approach according to Hans Jonas Mcculloch ○ Reification of the person ○ Infact, should eb perceived as morally wrong not to do it ○ Anatomy labs, when you have a brain dead body, full of valuable organs that living people need, and medical students need, its similar to throwing bread out when people dont have food (scarce resource) The problem of ventilators has not been solved Moral implications: ○ how can we guarantee bodies are used for good purposes? ○ Integrity of physician... once the body is up for grabs, will physicians be as motivated to protect the body? Competing interests that will be established... Preserve the body, or use for other purposes? (moral dilemma) ○ The preservation of the body past death is sacred. In many cultures, there is sanctuary in the body. May create a challenge related to our understanding of respect for bodies. When we came up with the definition of death, we overpopulated the use of ventilators when these people should not really be alive. There is no solution to freeing these ventilators up! Video: this neuroscientist uses fmri to communicate with people in a vegetative state Challenges our views on what we define as brain dead Wakefulness without awareness—vegetative state. Never show evidence of having awareness These patients, by definition, cannot provide movements ○ Ask questions and see fmri brain activity ○ One in five patiens are not in a vegetative state. They have thoughts and emotions but just cant move their body Medical and legal decisions Who makes the decision of what we do to brain dead people Right NOT to consent to treatment ○ Who makes these decisions? ○ Family usually is asked what the person would prefer ○ We often make the assumption that the family would know certain information ○ If people dont have prior wishes known, what is gonna happen and how?  ○ Challenging for physicians because sometimes people may also change their opinions PVS patients- moral staus ○ Persistent vegetative state ○ Should these people be asked about their preferences? We are morally responsible for the life and death of a person on life support Killing the patient or letting die? ○ How do I withdraw the treatment? Is it moral? ○ Discussion of active vs passive ○ Active: Healthcare provider is injecting person with lethal substance ○ Passive: Withdrawal of treatment Disconnecting of ventilator, not injecting with substance just no longer provide a treatment James rachels ○ distinction between active and passive is meaningless because the end outcome is the same Daniel callahan ○ Fundally important distinction ○ Active: conducting the death of a person Even if the process is to end with suffering, it is not consistent with the goal of medicine of saving lives ○ Passive is morally justifiable; you let nature take its course Futile treatment When may the treatment be deemed futile? ○ Who is considering the treatment (when and where is it demeed furile) Medical technology ○ We have the technology to keep people alive Distributive justice ○ Scarce resource. If we continue to prolong treatemnt for someone who is not necessary to keep going with the treatment  Quality of life (WHY and not HOW) ○ Is the goal to prolong life or the quality of life ○ Who makes the decision of what is the quality of life Who defines futile treatment? ○ 1. Patient’s autonomy and right to refuse treatment ○ 2. Doctor’s right to limit treatment Euthanasia and assisted suicide active/passive euthanasia Voluntary: wishes of the patient Non-voluntary- wishes of the surrogate ○ Side with family assuming they knwo what the patient would want Involuntary - without consent ○ Illegal: death without their consent Assisted suicide - the patient is to bring about death on their own Callahan: if you think about what is assisted suicide, its consenting adults killing ○ Problematic: ethically not coenciding with responsibility with medicine ○ Medicine is with helping people and prolonging life Assisted dying: Pros and Cons Canada: Right to die legislation / Medical assistance in dying https://www.canada.ca/en/health-canada/services/medicalassistance-dying.html Arguments against: Slippery slope ○ Involuntary euthanasia People are allowed to be applied to MAID, maybe healthcare professionals will be less disinterested in treatment, knowing how costly it will be , knowing we can apply for maid Homelessness: approved for maid, inability to get a good quality of life. Example of misuse ○ Releasing the loved ones from burden of care Keenan: Women and euthanasia ○ Gendered mature ○ Women receive burden of care but when its time for someone to care for them, they often do not want to be a burden for family ○ Desire to apply for MAID  ○ As seen on presentation, not really so because men are just likely to apply for maid ○ Even though there are safeguards for maid, their not always in place. Conclusion: Technological progress is a two-edged sword Part of every good life is a good death What you need to know for the exam: All concepts and definitions Changing meaning and definition of death Ethical theories’ approaches do death, assisted dying and futile treatment Content of guest lectures  Chapter 8: death and dying ummary of Euthanasia and Suicide Historical views: ○ Ancient Greece: Euthanasia was not uncommon. Plato (believed in the immortalaity of the soul) opposed suicide, believing life belonged to the gods, while Stoics (who did not believe in life after death) accepted it as rational if illness made life unbearable. ○ Christianity: Always condemned both suicide and euthanasia, even as acts of mercy. ○ Asian religions: Suicide is viewed as one of three forms of self-willed death: heroic, religious, or due to terminal illness/old age. The religious form is often considered rational and acceptable. Socrates: certain conditions pf living can be worse than dying Plato believed in a differfent immortality than the christian one - he believed in reincarnation ○ True philosopher does not fear- and even seeks dath Hume - all answers to death could not be known by the finate mind Kant believed in immortality ○ We will continue to perfect ourselves in the after life  We now stave death off for as long as possible, we arent used to death like we used to be ○ Death is seen less as an inevitable fact of life and more as a failure of medical technol- ogy Technology and the meaning of death w e may be living longer but were not lving healthier lives In some cases the suffering at end of life comes from these technologies The doctor, not nature is in charge Definitions of death Traditionally, death was determined by heart ad lung function ○ A personw as dead when they couldnt breathe and their heart stipped ○ Cardiopulmonary definition of death Summary: Definitions of Death Traditional Definition (Cardiopulmonary): ○ Death was traditionally determined when breathing and heart function stopped. ○ This worked until the late 1960s, when technology (mechanical respirators) and organ transplantation began to complicate the definition. Impact of Technology: ○ Mechanical respirators allowed people to be kept alive indefinitely, blurring the line of death. ○ Organ transplantation required clarity on when a person was dead to avoid ethical issues in organ procurement. Harvard Medical School Committee (1968): ○ The Committee created the "whole brain" definition of death: a person is considered dead when there is irreversible cessation of brain functions, including the brainstem, or the irreversible cessation of heart and lung function. ○ This definition addressed the need to clarify death for organ donation purposes. ○ Adopted by major medical associations (World Medical Association, Canadian Medical Association). Whole-Brain vs. Higher-Brain Debate: ○ Whole-brain definition: Death is when the entire brain (including the brainstem) stops functioning.  ○ Higher-brain definition: Death is defined by the irreversible loss of cognitive functions, not all brain functions. ○ The higher-brain criterion would consider people with no consciousness but still breathing as dead, allowing for organ donation even if the heart and lungs were still functioning with support. Key Points: ○ The definition of death has evolved due to technological advances. ○ The whole-brain definition became the standard in the Western world, but the higher-brain definition challenges the need for all brain functions to cease for death to be declared The Status of Brain-Dead Patients Ambiguity of Brain Death: ○ Brain-dead individuals remain physically alive with functioning heart and breathing, leading to debates on whether they are truly dead. ○ A case of a brain-dead woman kept alive for three months to deliver her baby illustrates this ambiguity. Although she was considered legally dead, her body continued to nurture a fetus and then was deemed to have "died" after giving birth. Ethical Concerns: ○ The concept of brain death raises questions about how to treat patients whose bodies may be kept alive through life support, but who are considered dead by the brain-death definition. ○ The treatment of brain-dead bodies has evolved to view them as resources for organ transplantation or other purposes, which some bioethicists see as a form of "reification" (treating a person as an object for use by others). Organ Donation and Use of Brain-Dead Bodies: ○ Some researchers argue that brain-dead individuals should be treated as cadavers, allowing their organs to be harvested for transplantation or for use in other medical research, such as xenotransplantation (transplanting animal organs into humans). ○ Others suggest that brain-dead women could be used to gestate IVF-produced fetuses, further extending the debate on the ethical use of such bodies. Dilemmas in Medical Practice: ○ The definition of brain death may not fully solve the problem of life-sustaining treatment for patients who show no hope of recovery. Instead, overtreatment (continued life support without meaningful survival prospects) remains a widespread issue.  ○ There is a tension between treating brain-dead individuals as living beings (with respect for life) and using them as resources for organ donation and research, creating a conflict between respecting life and utilizing the bodies of those deemed legally dead Killing and Letting Die Human Responsibility for Death ○ Advances in technology have transformed death into a human decision, creating a sense of moral responsibility for life or death decisions. ○ Disconnecting life support is often viewed as "killing" rather than allowing natural death. Killing vs. Letting Die ○ Passive euthanasia (letting die) is generally accepted, involving withdrawal of futile treatments to allow natural death. ○ Active euthanasia (direct action to cause death) is mostly illegal and considered immoral in many jurisdictions. James Rachels' View ○ Rachels argues that the distinction between active and passive euthanasia is artificial, as both aim to end suffering. ○ Passive euthanasia can prolong suffering, while active euthanasia offers a quicker, less painful death. ○ Withdrawal of treatment is an action and not merely passive non-interference. Callahan's View ○ Callahan emphasizes preserving the distinction, seeing withdrawal of treatment as allowing death from disease, not causing it. ○ A physician's non-treatment affects only a terminally ill patient, not a healthy one, distinguishing it from active killing. ○ The distinction clarifies the limits of human control over death and respects natural causes. Ethical and Moral Questions ○ The debate raises issues of control over death, patient suffering, and the morality of ending life. ○ With technology extending life, it is debated whether decisions to stop treatment are moral or natural. ○ Responsibility for death shifts between human action and natural causes, challenging ethical boundaries. Summary of Key Points on Futile Treatment 1. Definition and Challenges: ○ Futility in treatment involves interventions that provide no meaningful benefit to the patient. ○ Disagreement exists on what constitutes futility—some view all life as sacred, regardless of consciousness, while others prioritize patient-defined goals and quality of life. 2. Ends of Medicine: ○ Medical goals should focus on the overall benefit to the patient rather than merely maintaining biological functions. ○ Treatments prolonging life without improving health or quality may not align with the true objectives of medicine. 3. Two Conflicting Rights: ○ Patient Autonomy: Patients have the right to refuse or request withdrawal of treatment they consider futile. ○ Physician Autonomy: Physicians may resist providing treatments deemed futile, balancing ethical principles like beneficence (doing good) and non-malfeasance (avoiding harm). 4. Legal Cases and Precedents: ○ Landmark cases (e.g., Quinlan, Cruzan, Rasouli, and Wanglie) highlight disputes over who decides when treatment is futile. ○ Courts often favor patient autonomy or family decisions over physicians' judgments, even if treatments are considered futile. 5. Resource Allocation: ○ Futile treatments raise issues of distributive justice, particularly in public healthcare systems like Canada, where resources are scarce. ○ The moral and financial costs of prolonging life in such cases can strain healthcare systems and challenge the fairness of resource allocation. 6. Ethical and Moral Considerations: ○ The preservation of biological life may conflict with the values of quality life and efficient resource use. ○ Differing views exist on whether maintaining life support aligns with moral obligations, especially when consciousness or recovery prospects are minimal. Summary of Key Points on Feeding Tubes Legal Perspective: ○ In the Cruzan case, the U.S. Supreme Court ruled no distinction between withdrawing ventilators and feeding tubes as life support. ○ Artificial hydration and nutrition via feeding tubes are considered medical treatments that can be refused or withdrawn.  Emotional and Ethical Challenges: ○ Feeding is emotionally charged, and withholding it can be perceived as starvation rather than allowing natural death. ○ Ethical dilemmas arise, especially with PVS patients, who may live decades with artificial nutrition despite being in a state some equate with higher-brain death. Advocacy for Continued Feeding: ○ Advocates argue that PVS patients are alive, not actively dying, and require minimal effort to sustain. ○ They see human life as sacred and feel morally obligated to provide artificial nutrition and hydration. Critique of Feeding Tubes: ○ Callahan highlights that inability to eat is a natural symptom of terminal illness, allowing the body to shut down peacefully. ○ The introduction of feeding tubes created a new moral obligation that challenges the acceptance of death as inevitable. Technological and Moral Questions: ○ The availability of technology like feeding tubes challenges traditional distinctions between life and death. ○ Ethical evaluation should consider the purpose ("why") of using medical technology, not just its feasibility ("because we can"). Summary of Key Points on Euthanasia and Assisted Suicide Concept and Terminology: ○ Euthanasia means “a good death” and aligns with the belief in the right to die with dignity. ○ Active euthanasia involves intentionally ending a life, often via lethal injection. ○ Passive euthanasia refers to withholding or withdrawing life-sustaining treatment, but is generally not classified as euthanasia anymore. ○ Assisted suicide occurs when a patient ends their own life with the assistance of another, such as a doctor prescribing lethal medication. Types of Euthanasia: ○ Voluntary: At the request of a competent patient or with clear advance directives. ○ Non-voluntary: Requested by a surrogate, often based on the patient's known wishes. ○ Involuntary: Without or against the patient's consent, often equated to murder. Legal Developments:  ○ Key cases (Rodriguez v. British Columbia and Carter v. Canada) have influenced Canadian law, leading to the legalization of medical assistance in dying (MAID). ○ Assisted suicide was decriminalized in Canada in 1972, but aiding suicide remained illegal until recent rulings. Arguments in Favor: ○ Autonomy and Self-Determination: Individuals should have the right to choose a dignified death and avoid prolonged suffering. ○ Euthanasia is seen as consistent with a physician’s role to alleviate suffering and care for the patient holistically. Arguments Against: ○ Callahan argues that euthanasia involves others and challenges the principles of autonomy and the sanctity of life. ○ Concerns about a “slippery slope,” where legalizing voluntary euthanasia could lead to abuses or involuntary euthanasia. Ethical Dilemmas: ○ The sanctity of life principle clashes with arguments for personal autonomy. ○ Opponents fear the erosion of societal taboos against taking life, despite studies from Oregon and the Netherlands showing no disproportionate impact on vulnerable groups Summary: The Slippery Slope Argument on Euthanasia Overview of the Argument: ○ Slippery slope arguments suggest that allowing euthanasia in limited, morally acceptable cases could lead to morally unacceptable outcomes. ○ Critics argue that legalizing euthanasia for terminally ill patients in pain might extend to broader cases, ultimately leading to involuntary euthanasia. Philosophical Concerns: ○ Philosophers often classify slippery slope arguments as logical fallacies due to a lack of evidence for inevitable progression. ○ Critics like Callahan argue that the core motives for euthanasia (autonomy and relief from suffering) can logically become uncoupled, leading to abuse: If autonomy is the primary value, suffering should not be required. If relief from suffering is the priority, competence should not be necessary. Real-World Concerns:  ○ Examples like Belgium's law permitting euthanasia for suffering children (with parental consent) illustrate potential de-linking of competence and suffering criteria. ○ Critics fear that societal acceptance could coerce vulnerable individuals (e.g., elderly or infirm) into requesting euthanasia to avoid being burdensome. Potential for Coercion: ○ Legalizing euthanasia might create implicit pressure for individuals to justify their continued existence. ○ Patients might request euthanasia not from true autonomy but to alleviate perceived burdens on family or society. Alternative Perspectives: ○ Warnock contends that it is insulting to assume patients lack autonomy in requesting euthanasia. ○ Some view such requests as altruistic, motivated by a desire to minimize suffering for loved ones and society. Callahan disagrees with the interpretation of autonomy and relief from suffering as outlined in the slippery slope argument for euthanasia. Here's why: Autonomy: ○ Callahan rejects the idea that autonomy justifies euthanasia, emphasizing that euthanasia involves another person (e.g., a doctor), not just the individual making the decision. ○ He argues that autonomy does not logically extend to giving another person the right to kill, as this undermines the inalienable nature of the right to life. ○ He cautions against the notion that anyone should have the right to be killed "for any reason that suits them," highlighting the dangers of extending autonomy too far. Relief from Suffering: ○ Callahan questions why suffering alone should justify euthanasia, especially when it might apply to individuals who cannot consent (e.g., those who are incompetent). ○ He opposes the uncoupling of suffering from competence, as it could lead to decisions being made on behalf of individuals without their explicit and informed consent. ○ He believes that prioritizing relief from suffering over the preservation of life could lead to unintended abuses, such as society or medical professionals determining whose life is worth living. In summary, Callahan critiques the application of autonomy and relief from suffering as justifications for euthanasia, arguing that they lack logical stopping points and risk leading to societal and ethical abuses. Summary of Medical Assistance in Dying in Canada (MAID) Legislation and Criteria: ○ Legalized on May 31, 2016, following two Supreme Court of Canada decisions. ○ Criteria for eligibility: Serious and incurable disease or disability. Advanced state of irreversible decline. Enduring and intolerable physical or psychological suffering. Death must be "reasonably foreseeable" (no specific time frame provided). Voluntary request, informed consent, and mental competence required. Key Legal Amendments: ○ Criminal Code sections 241(b) (assisted suicide) and 14 (voluntary euthanasia) were amended. ○ Exemptions apply only to physicians and nurse practitioners, not others. ○ Provides two options: Practitioner-administered death. Self-administered death with practitioner-provided substances. Historical Cases: ○ Sue Rodriguez: Denied request for assisted suicide. ○ Gloria Taylor: Broader request for "physician assistance in dying" accepted, leading to legal change. ○ Supreme Court decision included both euthanasia and assisted suicide under MAID. Criticism and Support: ○ Support: Civil liberties groups advocate for patient rights and oppose prolonged suffering. ○ Criticism: Religious groups worry about the impact on vulnerable populations. Concerns about judicial activism (court making rather than interpreting laws). Some argue for increased investment in palliative care as an alternative to MAID. Fear of discouraging other options for terminally ill patients. Advocacy for Reforms:  ○ Groups like Dying With Dignity call for: Advance directives to allow MAID based on prior consent. Broadening eligibility criteria, such as removing the "reasonably foreseeable death" requirement. Legal Challenges and Changes: ○ 2019: Quebec Superior Court struck down the "reasonably foreseeable death" requirement, calling it unconstitutional. ○ British Columbia case highlighted discrepancies in interpreting eligibility. ○ 2020: Bill C-7 proposed amendments to allow MAID for non-imminent deaths with stricter criteria. Implementation and Challenges: ○ Federal legislation applies nationwide, but provinces and territories implement it. ○ Different interpretations of criteria and discretion left to individual physicians create variability in access. Summary of Women and Euthanasia Gender Disparities in Euthanasia: ○ Women disproportionately request euthanasia or physician-assisted suicide, often due to feelings of being a burden to others. ○ Keenan argues this reflects social failure, not autonomy, citing examples of elderly, often impoverished women with chronic illnesses and inadequate medical care. ○ Dr. Kevorkian’s first eight assisted cases were women, many of whom were not terminally ill. Context and Social Factors: ○ Women are more likely to outlive men, leading to isolation, poverty, and dependence. ○ Social and systemic issues, such as inadequate health coverage and societal expectations of self-sacrifice, influence women's decisions. ○ Requests for euthanasia may stem more from despair and inadequate support than genuine desire for death. Feminist Critique by Susan M. Wolf: ○ Problems with the Rights Argument: Overlooks the patient's context, including relationship failures, inadequate care, and constrained choices. Depicts individuals as isolated, ignoring their embeddedness in social and relational contexts. ○ Extolling autonomy may discourage exploration of alternative supports, such as improved care or social resources.  Caution Regarding Gender Bias: ○ Feminist analysis highlights risks of gender bias in euthanasia, as women have historically been subject to bodily invasions, self-sacrifice, and societal subordination. ○ Wolf emphasizes the importance of resisting these patterns, advocating for careful scrutiny of euthanasia requests. Physician’s Role: ○ Debate centers on what physicians may ethically do in response to euthanasia requests, not simply on patients' rights to ask. ○ Wolf argues against physicians assisting suicides, emphasizing the dangers of normalizing such actions and the historical context of women’s subordination. Contrasting Domains of Autonomy: ○ Wolf supports women’s rights to refuse unwanted bodily invasions, citing historical harm from violations like rape. ○ She opposes framing euthanasia or assisted suicide as a right, due to the dangers of perpetuating harmful gendered patterns Summary of Key Points on Ethical Theories in End-of-Life Treatment Kantian Ethics Principle of Autonomy: ○ Supports refusal of life-sustaining treatment as a moral right. ○ Opposes euthanasia and assisted suicide, viewing suicide as a contradiction to freedom and duty. Duty and the Categorical Imperative: ○ Autonomy requires responsibility; using scarce medical resources for futile treatment violates the principle of universalizability. ○ Physicians’ professional autonomy is respected, allowing them to refuse futile treatment responsibly. Severely Impaired Newborns: ○ Newborns are not considered "persons" in Kantian ethics, so the principle of respect for persons may not apply. ○ Parents' autonomy is supported, granting them decision-making rights for their infants’ treatment. Utilitarian Ethics Focus on Consequences: ○ Emphasizes maximizing overall good and minimizing harm.  ○ Supports resource allocation that benefits the majority, discouraging over-treatment of terminally ill patients. Euthanasia and Assisted Suicide: ○ May be morally acceptable if the consequences (e.g., relief of extreme suffering) outweigh the harms. ○ Considers societal and familial impacts in evaluating ethical acceptability. Severely Impaired Newborns: ○ Quality of life and the burdens on parents and society are central to decision-making. ○ Parental autonomy may be overridden if consequences of treatment are deemed too burdensome. Virtue Ethics Holistic Approach: ○ Ethical decisions are situated within the context of a person’s entire life, aiming for a flourishing and virtuous life. ○ Death is viewed as a natural part of life, requiring virtues like courage and moderation. Treatment Decisions: ○ Rejects over-treatment, emphasizing moderation and avoidance of futile care. ○ Encourages patients to focus on what aligns with their flourishing rather than asserting rights. Euthanasia and Hospice Care: ○ Supports a “good death” integrated into a virtuous life, with preference for hospice care over aggressive ICU treatment when medical returns diminish General Points on Philosophical Reflections on Death and Dying Metaphysical Nature: Discussions about death often rely on metaphysical or a priori reasoning, as they deal with concepts like the soul, life after death, and immortality, which are beyond sensory experience. Western Traditions: ○ Plato: Advocated the idea of the soul’s immortality and reincarnation, viewing life as a preparation for death, with death being a release of the soul from the body. ○ Aristotle: Argued that the soul and body are inseparable, perishing together at death, viewing death as the natural end of life. Dual Perspectives on Death:  ○ Death as Transformation: Reflects a belief in life after death, often relying on supernatural explanations. ○ Death as Finality: Emphasizes natural explanations, seeing death as the ultimate end, with no continuation beyond life. Body and Soul Debate: ○ Platonic tradition separates the soul and body, influencing thinkers like Augustine, Descartes, and Kant. ○ Aristotelian tradition sees them as inseparable, influencing naturalist philosophers like the Stoics, Epicureans, Hobbes, and Hume.