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Saturday, April 19, 2014

Disconnecting Life Support


A Kantian and Utilitarian approach to disconnecting a Persistent Vegetative State patient from a respirator

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 patient from a respirator
            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):

  1. Consequentialism: consequences count, not motives or intentions.
  2. The maximization principle: the number of people affected by consequences matters; the more people, the more important the effect.
  3. A theory of value (or of good): Good consequences are defined by pleasure (hedonic utilitarianism).
  4. 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)
(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: McGraw-Hill.
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)  



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