A Kantian and Utilitarian approach to disconnecting a
Table of contents
1. Introduction
2. The Persistent
Vegetative State
3. Outline of
Kantian Approach
3.1 Distinctive elements of a
Kantian approach
3.2. Some problems in Kantian Ethics
3.3. Conclusion
4. Outline of
Utilitarian Approach
4.1. Basic Tenets
4.2. Strengths
4.3. Weaknesses
5. Disconnecting a
Persistent Vegetative State
5.1. Kantian Response
5.2. Utilitarian Response
6. Conclusion
7. Reference list
8. Declaration
Introduction
The decision to
disconnect a patient in a persistent vegetative state (PVS) is one which will
(probably) determine whether the patient continues to live or die. It is a
moral decision which will have different outcomes, depending on whether one
takes a Kantian or Utilitarian approach in making that decision.
In this essay, I
will give a brief description of the permanent vegetative state followed by a
more detailed account of each of the Kantian and Utilitarian approaches. I will
then apply each approach to the issue of disconnecting the respirator from the PVS
patient, highlighting the differences between the two and I will make some
concluding remarks.
The Persistent Vegetative State (PVS)
Howard and Muller
(1995:341) describe the PVS as a serious form of coma in which there is deep
unconsciousness which is almost always irreversible if it persists for a few
months. There are often inconsistent non-purposive movements, notably facial
grimacing and chewing.
According to Jennet
(1992:1305), because of the degree of brain damage in PVS patients, they do not
experience hunger and thirst.
3. Kantian Approach
Immanuel Kant
published during the Enlightenment and believed that humans have power to use
reason to solve their problems.
The focus of
Kantian Ethics is on ideals of universal law and respect for persons.
3.1. The following
are some of the distinctive elements of Kantian ethics, summarized from Pence (2004:16-18):
Ethics is a matter of duty, not of consequences – the reason for the act is more important than its good or bad
results. All acts should be done from the right motive and the right motive is
always to do one’s moral duty.
In Kantian ethics, any acts done from duty and not, for example from
compassion, are praiseworthy. According to Kant, when we act morally, reason
tells feelings what to do. A good will which is the trait of character indicating
a willingness to choose the right act simply because it is right is the only
thing valuable in the world. In order to know what is right and what is our
duty, Kant gives this formulation:
A right act has a maxim that can be universalized.
A right act always treats other people as ends in themselves and
never as mere means to an end
Every person has absolute, infinite moral worth. No person has
relative worth. Therefore, one person’s welfare cannot be sacrificed to the
good of others or to one’s own desires.
People are only free when they act rationally
According to Pence (2004:17) “Kant
would agree that much of how we act is governed by our emotions and other, non
rational parts of upbringing. But, controversially, Kant denies that we are
truly acting morally when we do the right thing because we are accustomed to
it, because it feels right or because society favours the act. The only time a
person can act morally is when she exercises her rational, free will to
understand why certain rules are right and then chooses to bind her actions to
these rules. Kant calls the capacity to act this way, autonomy.”
The above quotation emphasizes the Kantian belief in the supremacy
of reason and rule over feelings and consequences. One conclusion to draw from
all this is that very few people act morally. “The purity of Kant’s view
entails a moral elitism for the few who can successfully follow Kantian Ethics”
(2004:17)
Kant distinguishes between duties to ourselves, duties to others,
perfect duties and imperfect duties. Perfect duties, also called ‘negative
duties,’ (“don’t”), are supreme and allow no exceptions at all. Imperfect
duties (or positive ‘do’ duties) can be overridden by perfect duties.
3.2. Some problems in Kantian Ethics
Kantian Ethics do not help us to decide between two competing,
universalizable maxims. The treating of every human being as having infinite
value is not always practical. For example in triage situations where some
people will die and thus cannot be treated as “ends in themselves”
3.3
Conclusion
One could say that Kantianism does not aim at producing some good;
rather it is concerned with why one acts. It seeks to maintain disinterested
devotion to moral duty.
4. Utilitarianism
The essential idea
of Utilitarianism is “utility” which means right acts should produce the greatest
amount of good for the greatest number of people. It is a consequentialist,
moral theory in which the ends (consequences) justify the means (actions). This
naturally leads to the realisation that actions are neither right nor wrong;
rightness or wrongness depends on the consequences. Utilitarian’s see morality
as a human construct that should minimise harms of humans to each other and
maximise group welfare.
4.1.
Utilitarianism’s essence can be summed up in four basic tenets, summarized from
Pence (2004:18-21):
- Consequentialism: consequences
count, not motives or intentions.
- The maximization principle: the
number of people affected by consequences matters; the more people, the
more important the effect.
- A theory of value (or of good):
Good consequences are defined by pleasure (hedonic utilitarianism).
- A scope of morality premise: each
being’s happiness to count as one and no more.
For
utilitarianism, right acts produce the (2) greatest amount of (3) good (1)
consequences for the (2) greatest number of (4) beings.
All actions are
judged according to whether they augment or diminish the happiness of those
affected by the action. The pursuit of one’s own pleasure will be modified to
take account of the pleasures and pains of others and to co-operate in the
production of pleasure and avoidance of pain for others.
Utilitarianism is
called positive utilitarianism when it focuses on benefitting humanity.
Negative utilitarianism focuses on relieving the greatest misery for the greatest
number. The utilitarianism discussed thus far is called Act utilitarianism
where the consequences of an act determine its moral worth and utility is
maximised by maximising happiness. Rule utilitarianism rejects the greatest
happiness principle and believes that the normal moral rules maximise utility
over decades. Such a moral rule in medicine would be “first do no harm”. While
they claim that an act is only permissible if it follows from a rule whose
adaption by almost everyone would maximise happiness, they allow breaking that
rule in special circumstances where breaking it will in fact bring about
maximum happiness.
However, Judith
Thomson (1985:1395-1415) points to the principle that rights trump utilities
and says “if one would infringe a right in or by acting then it is not
sufficient justification for acting that one would thereby maximise utility”(1985:1404).
4.2. Some of the
strengths of utilitarianism are that it offers a relatively clear procedure for
finding out the right thing to do and it solves conflicts by examining the
consequences of each option.
4.3. Some of the
weaknesses of utilitarianism are that it does not take account of special
obligations to people with whom we have special relations; also individual rights
are outweighed by social needs; and it can allow for innocent suffering if such
suffering produces beneficial results.
5. Disconnecting a patient in a PVS from a respirator
Having discussed
very briefly, the basic tents of each approach, I will now look at the specific
approach each might take.
5.1 The Kantian response
The pure Kantian
probably has the eaiest arrived at answer. We have a perfect or negative duty
to not kill, which is supreme over all other duties. Removal from the
respirator will cause the death of this patient and is tantamount to killing. (Please
note that I have assumed that the moral issue alluded to in the title of this
essay is that death is inevitable on the removal of the respirator even though according
to Howard and Miller (1995:341) some PVS patients breathe naturally and others
like Karen Quinlan have according to Pence (2004:39) been successfully ‘weaned’
from the respirator.)
However, as
outlined in the discussion above on Kantian ethics, the Kantian has recourse to
other avenues. The Kantian respect for humanity and its outcomes in the
principles of beneficence and non-maleficence mitigate against any action that
might harm the patient, and in Kantianism death is seen as a harmful outcome.
Furthermore, according
to Pence (2004:62) Kant held that we have a moral duty to live because our
lives are not really our own possession and he quotes Kant’s appeal to
authority: “Human beings are sentinels on earth and may not leave their posts
until relieved by another beneficent hand. God is our owner, we are His
property.” While he said this in the context of suicide, it implies that for
Kant no one else but God has a say regarding when we die. (Please note this is
not my fallacious appeal to
authority, but Kant’s)
A Kantian who
could not remain disinterested and really wanted to help the PVS patient to die
would perhaps try and develop a universal rule allowing removal from a
respirator: “All PVS patients who have been in that state for a year or longer
ought to be disconnected from the respirator.” However, that same Kantian would
need to concede that the right to not be killed outweighs all other rights.
I believe the
Kantian would find great difficulty in justifying the removal of the
respirator, but would be very relieved if the patient were to die ‘naturally’
and would even say that it was desirable for this death to happen. That same
Kantian would say that it would not have been right for us to have caused the
death. This is what James Montmarquet (1982:407) refers to as a “deep rooted
and inadequately studied feature of our Kantological moral outlook: the dual
standards it inevitably uses to evaluate the workings of nature and intentional
human actions.”
The Utilitarian Response
The Utilitarian
will ask questions regarding the happiness of all those involved. This would include the PVS patient, the family
of the patient, the care providers and the providers of the respirator.
A conclusion would
probably be reached that while the happiness of the PVS patient cannot be
known, the happiness of all the other parties can be known and will be
increased if the respirator is removed and the patient dies. This would be a
positive utilitarian approach.
A negative
utilitarian approach would consider the misery of everyone in the situation and
probably conclude that misery will decrease if the patient is removed from the
respirator and dies.
The Utilitarian
would also look at the avoidance of pain principle. While it is probably true
that persistent vegetative state patients do not experience pain (but we do not
know for sure), they often look as if they are in pain, through their
involuntary bodily movements and facial grimaces, and thus undoubtedly cause
pain in loved ones and care givers. Once again, the utilitarian would want to
minimise overall pain by removing the respirator.
The utilitarian
would also ask questions regarding the quality of life of the persistent
vegetative state patient and would probably believe that the patient in this
state has little or no quality of life and no chance of any improvement.
However Gavin Fairbairn (1997:144) has pointed out what a slippery concept quality of life has become and how
utilitarians give it different meanings depending on whether applied to the
beginning of life or the end of life.
The utilitarian
would have an easier time motivating removal of the respirator in a resource
poor country where respirators are in short supply and a greater burden is
placed on limited resources when PVS patients are ‘kept alive’. If the
respirator could be better utilised to maximize benefits (e.g. helping those
who will eventually recover fully) then the end would justify the means and the
patient would be disconnected.
6. Conclusion
A comparison of
Kantian and utilitarian approaches to the PVS patient shows that in ethics
there is more than one way to approach moral decision making. Whether morality
is founded on unchanging standards or whether moral rules change depending on
context and compassion are questions that are probably best approached with
humility and a willingness to consider all possibilities. The different ways of
thinking should not be seen as strictly distinct and in competition with each
other.
However, it is
imperative to move beyond discussions on various points of view and to
determine the underlying moral premise because it is only then that the
evaluative premise is revealed and only then can we begin to give reasons for
or against that premise.
7. Reference list
Fairbairn, G.
1991. Enforced death, Enforced life. Journal
of Medical Ethics Vol 17 No 3:144-149. Available: http://www.jstor.org/stable/27717051.
(Accessed 01/03/2010)
Howard R.S.,
Miller D.H. 1995. The Persistent Vegetative State. British Medical Journal, 310:341 Available http://0-www.bmj.com.innopac.wits.ac.za/cgi/content/full/310/6976/341?maxtoshow=&hits=10&RESULTFORMAT=1&andorexacttitle=and&titleabstract=The+persistent+vegetative+state&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=date&volume=310&fdate=1/1/1981&resourcetype=HWCIT
(Accessed
01/03/2010)
Jennet.B.1992.
Letting Vegetative patients die. British
Medical Journal, 305:1305. Available http://0-www.bmj.com.innopac.wits.ac.za/cgi/reprint/305/6865/1305?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=%22Letting+vegetative+patients+die%22&searchid=1&FIRSTINDEX=0&sortspec=date&resourcetype=HWCIT
(Accessed 01/03/2010)
Montmarquet, J.A.
1982. Messing with Mother Nature: Fleck and the Omega Pill. Philosophical Studies Vol 41:407-419.
Available: http://www.jstor.org/pss/4319532
(Accessed 01/03/2010)
Pence, G.E. 2004. Classic Cases in Medical Ethics. Fourth
Edition. New York
Thomson, J.J.
1985. The Trolley Problem. The Yale Law
Journal, Vol 94 No.6: 1395-1415 Available: Http://www.jstor.org/stable/796133
(accessed: 01/03/2010)
