J Med Ethics: first published as 10.1136/jme.7.2.74 on 1 June 1981. Downloaded from Journal of medical ethics, I98I, 7, 74-82

Debate: Extraordinary means and the sanctity of life

Helga Kuhse Department of Philosophy, Monash University, Clayton, Victoria, Australia

Editor's note doctors who have rejected the taking of human life since the fifth century BC when physicians first took Ms Kuhse argues against the doctrine of 'the sanctity the Oath of Hippocrates and swore to 'give no of life', against the application of acts and omissions deadly medicine to anyone if asked, nor suggest any doctrine in medical practice, and against the common such counsel'. But if a travesty of life has irretriev- assumption that there is a crucial moral difference ably lost all that seems to make human life valuable, between intentionally discontinuing ordinary medical then even the most ardent supporter of the doctrine treatment and intentionally discontinuing may feel that life ought not to be prolonged un- extra-ordinary medical treatment. Intentional acts necessarily. Faced with an absolute prohibition or omissions which shorten life are in practice and against the intentional termination of life, pro- must in theory be justified or rejected on the basis of ponents of the 'sanctity-of-life' doctrine argue that the quality of life concerned, she argues. Such it is then permissible to withhold or withdraw quality of life distinctions are needed in practice 'extraordinary' or 'disproportionate' means of life but they are logically incompatible with the support. Failure to provide 'ordinary' care is doctrine of the sanctity of life; and the ordinaryl generally seen as the intentional termination of life, extraordinary means distinction cannot circumvent or passive euthanasia. The cessation of 'extra- this incompatibility. ordinary' treatment, on the other hand, is Father Hughes in his conmnentary rejects Ms interpreted differently: it is regarded as the decision Kuhse's extretne interpretation of sanctity of life 'to provide the most appropriate treatment for that doctrine. He argues that the distinction between acts patient at that time' (2). and omissions is relevant to medical practice and The rationale underlying the distinction between distinguishes between two different senses of ordinary and extraordinary means is thus the ideahttp://jme.bmj.com/ 'omission' to support this. He finds Ms Kuhse's that there is a crucial moral difference between reliance on quality of life excessively reductionist intentionally discontinuing ordinary treatment and and argues that her position seems to commit her to intentionally discontinuing extraordinary treatment. denying any moral difference between intending a This beliefis very common; it is implied by the I973 death by withholding extraordinary treatment and policy statement of the American Medical Associ- intending a death by administering a lethal injection. Bonnie That there is an important moral distinction here is a ation (3), is supported by the philosopher Steinbock (4) and has most recently been recon- on September 25, 2021 by guest. Protected copyright. crucial intuition which supporters of the traditional firmed by Pope John Paul II in the Vatican's view wish to maintain, even though 'the difficulty ... 'Declaration on Euthanasia' (5). However, I believe is to discover a philosophical means to support it'. that it can be shown to portray either confused While sanctity of life doctrines need development, unrelated to the interests they express 'a healthy presumption in favour of thinking or a point of view trying to preserve it'. In a final response Ms Kuhse of individual patients. replies to her commentator. Readers' attention is drawn also to the review by 'Heroic' efforts and modern medical Professor Robin Downie on page 96 of a group of three technology papers entitled Prolongation of Life published by Sophisticated modem medical technology is the Roman Catholic Linacre Centre. achieving a continuously increasing control over our lives, and even if unable ultimately to conquer Many discussions within medical ethics, explicitly death, it has a lot to say about the conditions and or implicitly, appeal to and pivot on the 'sanctity-of- time of its occurrence. With this, an old question is life' doctrine. Yet the really critical issues in raised with renewed urgency: must human life, medicine are often hidden by 'the hulking darkness regardless of its quality, always be preserved? Is it of that concept'. Even those who disregard the the physician's duty to sustain indefinitely the life of clearly religious connotations (i) of the concept an irreversibly brain-damaged person by way of often employ it to argue that wherever there is artificial respiration and intravenous feeding? Must innocent human life, nothing must count against it; the physician engage in 'heroic' efforts, that is, innocent life must never be taken - especially not by employ all of modem medicine's devices to add J Med Ethics: first published as 10.1136/jme.7.2.74 on 1 June 1981. Downloaded from Extraordinary means and the sanctity of life 75 another few weeks, days, or even hours to the life of physician were to give a life-prolonging injection, a terminally ill and suffering cancer victim, or is it the patient would not die. Both killing and letting permissible to discontinue treatment ? Must active die thus constitute the 'intentional termination of treatment be instigated with regard to babies born so the life of one human being by another - mercy defective that their future promises little more than killing' and this is, according to the American continuous suffering or mere vegetative existence ? Medical Association, 'contrary to that for which the These questions are not new but they are, today, medical profession stands' (3). Euthanasia, whether posed with relentless clarity and urgency: Given active or passive, is thus absolutely prohibited. that we can sustain lives such as the above, ought If the 'sanctity-of-life' doctrine as it underlies the such lives to be sustained - and if not, why not? practice ofmedicine is absolute in this sense, there is Most of us would want to hold that there are, or another sense in which it is absolute as well: it should be, limits to the physician's duty to prolong makes no distinction between different types or life - but it is difficult to see how such limits can be qualities of human life-all life is of equal and incorporated within a 'sanctity-of-life' ethic that intrinsic worth. Chief Rabbi Jakobovits captures the absolutely prohibits the intentional termination of general thrust of the Judaeo-Christian tradition life and that sees all human life, regardless of its when he comments: 'The basic reasoning behind type or quality, as of infinite and intrinsic worth. the firm opposition of Judaism to any form of Here the 'can' would seem to imply the 'ought'. euthanasia proper is the attribution of infinite value Given that a human life can be prolonged by medical to every human life. Since infinity is, by definition, intervention, it ought to be prolonged - and it does indivisible, it follows that every fraction of life, not matter whether the life thus prolonged is however small, remains equally infinite so that it conscious, unconscious, painfree or irrelievably makes morally no difference whether one shortens filled with suffering. life by seventy years or by only a few hours, or When speaking of the 'sanctity-of-life' ethic, I am whether the victim of murder was young and robust not suggesting that the prohibition against the or aged and physically or mentally debilitated' (9). taking of human life has always been held in an Similarly, the Roman Catholic Church's position: absolute form, for this would imply total pacifism, 'It is necessary to state firmly one more that nothing exclude capital punishment, sacrificial heroism and and no one can in any way permit the killing of an killing in self-defence, practices which are not innocent human being, whether a foetus or an always condemned by supporters of the doctrine. embryo, an infant or an adult, an old person, or one But in the realm of medical practice, the 'sanctity- suffering from an incurable disease, or a person who of-life' ethic has ruled supreme for a very long is dying' (io). http://jme.bmj.com/ time (6). Here the intentional termination of life is On this view, not only does the distinction between not only absolutely prohibited, but the traditional acts and omissions not apply, but it is also irrelevant component of deontological ethics, the acts and whether or not it is in the patient's interest to have omissions doctrine, has no application in the his life prolonged. As one physician puts it: 'The doctor/patient relationship. Although medical patient entrusts his life to his doctor, and it is the appiications of the distinction between ordinary and doctor's duty to sustain it as long as possible. There extraordinary means are sometimes misinterpreted should be no suggestion that it is possible for the on September 25, 2021 by guest. Protected copyright. as applications of the distinction between acts and doctor to do otherwise, even if it were decided that omissions (7), it is widely accepted that it is no the patient were "better off dead" ' (ii). excuse for a doctor to say that he did not kill his Similarly, another physician: 'It is not the patient but 'merely' let him die by withholding privilege of any doctor to decide that he should life-saving treatment. Both medical ethics and the shorten life. The preservation of life must be the law impose a duty on the doctor to care for his sole principle guiding medical practice, including patient, which puts the doctor vis-a-vis his patient in treatment of the hopeless cancer patient. This a very different situation from that of an ordinary principle cannot be tampered with or interpreted citizen who omits to save the life of a stranger. loosely' (12). Indeed, the Vatican's Declaration on Euthanasia This attitude, whilst it may strike many as cruel defines 'mercy-killing' as 'an act or an omission and impervious to the interests of the patient, is which of itself or by intention causes death' (8). consistent with the 'sanctity-of-life' principle. It is, This is an extension of the rule 'Do not kill' however, not in accordance with generally accepted which, for doctors, now reads: 'Do not kill and do practice. Each year, thousands of defective infants not let die', ie, the absolute prohibition against are 'allowed to die' (I3), terminally ill patients do shortening the patient's life - even for compassion- not have their lives prolonged by all possible ate reasons - applies to both acts and omissions. means (I4), and the life-support of irreversibly Letting die, like killing, is absolutely prohibited, for comatose patients is withdrawn in the clear 'letting die', as understood here, always implies a knowledge that death will, in most cases, follow counterfactual conditional of the type: If D did Y, within minutes (15). then X would not happen. For example, if the But if lives such as these could be prolonged and a J Med Ethics: first published as 10.1136/jme.7.2.74 on 1 June 1981. Downloaded from 76 Helga Kuhse decision is taken against prolonging them, we appear regarded as optional (i8). As Pope Pius XII phrased to be confronted with the practice of passive it: euthanasia. However, if these practices are forms of euthanasia, then one would want to know how they . . . normally one is held to use only ordinary can be incorporated in a sanctity-of-life ethic that means - according to circumstances of persons, absolutely forbids the intentional 'hastening of the places, times and culture - that is to say, means that hour of death' (i6). The question is especially do not involve a grave burden for oneselfor another. baffling if, as I have suggested, the acts and omissions A more strict obligation would be too burdensome doctrine is out of place in the doctor/patient for most men and women and would render the relationship. For then what we have is a practice attainment of the higher, more important good too morally equivalent to active euthanasia. difficult ... (I9). An answer to this question has traditionally been Subsequent to this, the following standard definition given in terms of the distinction between 'ordinary' was adopted: and 'extraordinary' means of treatment. Whilst Ordinary means of preserving life are all medicines, failure to employ 'ordinary' means is generally treatments, and operations, which offer a reasonable identified with the intentional termination of life, hope of benefit for the patient and which can be failure to provide 'extraordinary' means is given a obtained and used without excessive expense, pain, different status. The Roman Catholic Church sees or other inconvenience ... Extraordinary means of it as 'a wish to avoid the application of a medical preserving life ... mean all medicines, treatments, procedure disproportionate to the results that can and operations, which cannot be obtained without be expected . . .' (i6). excessive expense, pain or other inconvenience, or Judaism, too, supports the distinction between which, if used, would not offer a reasonable hope of ordinary and extraordinary or 'artificial' means: benefit (20). We, too, would make a fundamental distinction However, a long history does not guarantee clarity between any deliberate hastening of death, whether and the Catholic Church has noted that even though with or without the patient's consent, on the one the extraordinary means criterion 'as a principle still hand, and the withdrawl of artificial means to holds good', a reformulation is indicated 'by reason sustain a lingering life in its terminal stages on the ofthe imprecision ofthe term and the rapid progress other, particularly when the recourse to such made in the treatment of sickness'. 'Thus', the

'heroic' methods would serve only to prolong the recent Papal statement continues: http://jme.bmj.com/ patient's agony. However, the sanction to discon- tinue treatment would not include the withdrawal of ... some people prefer to speak of 'proportionate food or other necessities of life (I7). and 'disproportionate' means. In any case, it will be possible to make a correct judgment as to the means And, in I973, the distinction between ordinary and by studying the type of treatment to be used, its extraordinary means of life-support moved from the degree of complexity or risk, its cost and the the it was possibilities of using it, and comparing these religious into secular realm, when on September 25, 2021 by guest. Protected copyright. employed in the AMA's policy statement. After elements with the result that can be expected, taking rejecting the intentional termination of life as into account the state of the sick person and his or 'contrary to that for which the medical profession her physical and moral resources (2I). stands,' the statement continues: In other words, a major factor in determining whether a means is optional, ie, extraordinary or The cessation of the employment of extraordinary disproportionate, is the 'state ofthe sick person' and means to prolong the life of the body when there is 'the result that can be expected'. A means can thus irrefutable evidence that death is imminent is the be either extraordinary or ordinary, depending on decision of the patient and/or his immediate the condition of the patient, and the adjective family (3). 'optional' ('extraordinary', 'disproportionate', If the above positions, Roman Catholic, Judaic and 'artificial') refers not simply to the treatment medical, are not to be blatantly self-contradictory, considered on its own, but to the treatment con- they must hold that the termination of extra- sidered in relation to the condition ofthe patient. As ordinary care is not the intentional or deliberate Bonnie Steinbock puts it: 'The concept is flexible, termination of life. andwhat mightbe considered "extraordinary" in one What, then, constitutes 'extraordinary' treat- situation might be ordinary in another' (22). While ment ? The language of extraordinary means has a the use of a respirator to sustain a patient through a long history - especially in the Roman Catholic severe but temporary respiratory ailment would be Church - where the employment of ordinary means regarded as ordinary, its 'use to sustain the life of a has always been seen as obligatory, whereas the severely brain-damaged person in an irreversible employment of extraordinary means was generally coma would be considered extraordinary' (22). J Med Ethics: first published as 10.1136/jme.7.2.74 on 1 June 1981. Downloaded from Extraordinary means and the sanctity of life 77

But here the term 'extraordinary' has been so by continued medical support. But quality-of-life relativised to the condition of the patient that it is criteria cannot be incorporated into a 'sanctity-of- precisely the condition ofthe patient that changes an life' ethic that regards all human life, irrespective of ordinary means into an extraordinary one. The its type or quality, as of the same intrinsic worth. respirator becomes an extraordinary means because According to the 'sanctity-of-life' doctrine, coma- the- patient's condition is extraordinary, ie, the tose human life has the same 'sanctity' as the life of patient's condition is unusual in the sense that in a conscious or self-conscious human being. Hence this particular situation, and contrary to the absolute this doctrine is incompatible with the way the tenets of the 'sanctity-of-life' doctrine, the pro- distinction between ordinary and extraordinary longation of the patient's life has become optional. means is drawn by Bishop Lawrence Casey and as it But if the kind of life that could be prolonged by is presupposed by the recent Papal Declaration on medical intervention is allowed to be relevant in the Euthanasia. decision as to whether or not a certain means will be The undefined use ofthe term 'human life' avoids employed, then we are implicitly moving from a a necessary task: it does not say what it is that gives 'sanctity-of-life' ethic to a 'quality-of-life' ethic. value to human life; it does not say what principles Such a move is also implied in Bishop Lawrence should serve as possible justification for the termin- Casey's support for the decision to remove Karen ation or continuation ofhuman life. While I have no Quinlan from the respirator because she 'has no way of refuting someone who holds that being reasonable hope of recovery from her comatose state physiologically alive, even though unconscious, is by the use of any available medical procedures. The intrinsically valuable, I can refute all those who want continuance of mechanical (cardiorespiratory) to combine this position with a limited duty of life- supportive measures to sustain continuation of her preservation in 'extraordinary' cases. The two body functions and her life constitute extra- positions are incompatible because the moral ordinary means of treatment' (23). Mechanical relevance ofthe adjective 'extraordinary', in this and supportive measures are extraordinary because, many other cases, must rest on quality-of-life con- while they sustain Karen's life, they sustain it only siderations, the moral relevance of which is being in a comatose state (24). It is the comatose state denied by the 'sanctity-of-life' doctrine. which is determinant, not the inherent 'extra- The important point is this: we are faced not ordinariness' of the means, nor the fact that Karen merely with a theoretical confusion, of interest only 'has no reasonable hope ofrecovery'. Ifthe recovery to philosophers and moral theologians, but with a were the continued use doctrine that has indefensible conse- criterion decisive, then also misleading http://jme.bmj.com/ of 'iron-lungs' for polio-victims and the continued quences in practice as well. Much of the current injection of insulin for diabetics would be extra- medical literature shows that there has been an ordinary and hence optional because they could not implicit shift to quality-of-life standards (26), and lead to recovery from the state of paralysis, nor cure sociological studies indicate how certain qualitative the diabetic condition. factors enter into medical decision-making in life However, all three forms of treatnent have one and death cases (27). But from an ethical perspective thing in common: their continued application will the quality-of-life question is not adequately treated prolong the patient's life. If it is thus permissible to until and unless one gives morally relevant reasons on September 25, 2021 by guest. Protected copyright. discontinue treatment in the one case but not in the as to why a certain quality or qualities should be other two, a defender of this view must point to a decisive in terminating or continuing life-pro- morally relevant difference that distinguishes these longing treatment (28). In practice this means that cases. It is not, as we have seen, the distinction the medical profession is, in the absence of such between ordinary and extraordinary means, con- standards, faced with an anarchy of values and sidered simply as means, and it cannot be the meaning. distinction between the intentional and the non- Thus doctors have applied (29), but - according intentional termination of life. Because if we accept to Steinbock - misinterpreted (30), the 'extra- (as most of us, even non-Catholics, would) that life ordinary means' criterion in situations like the can be terminated intentionally by either 'an action famous Johns Hopkins case, where a Down's or an omission which ofitself or by intention causes syndrome child requiring routine surgery for an death' (25), then withholding ofinsulin treatment or intestinal obstruction was 'allowed to die' by 'pulling the plug' of an iron lung would be examples dehydration and starvation over a Is-day period on of the intentional termination of life. But if 'pulling the grounds that surgery would have been an the plug' of a polio victim's iron lung is the inten- 'extraordinary' procedure. In cases like this, surgery tional termination of life, then - surely - 'pulling the can be withheld not because the treatment is, in any plug' of Karen Quinlan's artificial respirator is too. way, 'extraordinary'. but because the concept (Suppose she had died as a result). 'extraordinary' is 'extremely flexible'. If a child not If there is a morally relevant difference between afflicted with Down's syndrome is born with an such cases, it must lie elsewhere. And so it does. It intestinal obstruction, surgery to remove the lies in the different qualities or types oflife preserved obstruction is an 'ordinary' procedure. When a J Med Ethics: first published as 10.1136/jme.7.2.74 on 1 June 1981. Downloaded from 78 Helga Kuhse mongoloid child has such an obstruction, surgery certain circumstances, 'no reason to reproach him- becomes an 'extraordinary' procedure. Why? Not self with failing to help the person in danger' (35), because the nature ofthe operation has changed, but substantive criteria must be provided to tell us what because the child is a mongoloid. A mongoloid these circumstances are. In all those cases where child's life is given a different value from that of a death is not immIinent in spite ofthe means used, the normal infant. The 'extraordinary means' criterion physician is responsible for the death of the patient thus masks a quality-of-life judgment which may when he decides not to operate, to discontinue well require - but does not receive - further treatment, or to turn off the artificial respirator. As justification (why is it in a mongoloid infant's Robert S Morison puts it: interest to die ?) (3I). Furthermore, if euthanasia for Squirm as we may to avoid the inevitable, it seems mongoloid infants can be justified, why then only time to admit to ourselves that there is simply no for those with an intestional obstruction requiring a hiding place and that we must shoulder the re- simple operation? The answer is that in the latter sponsibility of deciding to act in such a way as to case, but not in the former, the 'extraordinary means' hasten the declining trajectories of some lives, while criterion can be invoked to mask a quality-of-life doing our best to slow down the decline of others. decision that is incommensurable with a 'sanctity-of- And we have to do this on the basis ofsome judgment life' ethic. (36). By presenting quality-of-life decisions as an on the quality of lives in question almost technical question, namely as one concerning When the Nuer, an East African tribe, saw a need 'means' which may or may not be optional, sub- to do away with defective infants, they did it by stantive moral issues are evaded. One of these is the classifying these defective infants as 'hippopota- question of what it is that we value when making musses', mistakenly born to human parents. These quality-of-life decisions. If we decide that 'certain infants were put into the river - their natural heroic intervention is not worthwhile' (32), ie that habitat. This was not killing Nuer infants, it was the value of an individual's life is insufficient to doing what was appropriate for young hippopota- warrant continuation of life-prolonging efforts, this musses; and Nuer morality, prohibiting the taking requires a clear assessment ofthe locus ofthat value of tribal life, could emerge unscathed (37). and if it derives from different sources, their relative When we allow defective infants to die by weights. As long as such substantive criteria are not classifying as 'extraordinary' the means used to keep made explicit in medical decision-making, as long as them alive, we are resorting to an equally spurious we rely on the extreme flexibility of the concept of device in order to preserve unscathed our sanctity-http://jme.bmj.com/ 'extraordinary means' to make a sanctity-of-life ethic of-life ethic. If we want to go beyond definitional superficially credible, we will engage in muddled ploys, we must accept responsibility for our life- practice. Doctors will let infants die by withholding and-death decisions, we must drop the traditional 'extraordinary' or 'disproportionate' treatment on sanctity-of-life ethic and embrace a quality-of-life the basis 'that prognosis for meaningful life [is] ethic instead. extremely poor. . .' (33), without, however, beingable to provide substantive criteria as to what,constitutes a 'meaningful life'; they will also resuscitate six Acknowledgment on September 25, 2021 by guest. Protected copyright. times the 68-year-old doctor suffering from I wish to thank Professor Peter Singer of Monash terminal cancer (34) on the basis that resuscitation is University for his encouragement and for his many now an 'ordinary' procedure in the modern hospital helpful comments and criticisms of an initial version setting. They will do so without being able to say of this paper. what value or values they are trying to serve, other than to act in accordance with a 'sanctity-of-life' and notes ethic that is impervious to the interests ofthe patient. References The point is that in our age of sophisticated (i) Caouser K D. The 'sanctity of life': an analysis of a in concept. Amnals ofinternal medicine 1973; 78: 124. medical technology death is often not 'imminent (2) Steinbock B. The intentional termination oflife. In: spite of the means used' (35). Death can often, quite Steinbock B, ed. Killing and letting die. New Jersey: literally, be kept waiting by the bed or the machine. Englewood Cliffs, I980; 74: first published in It is only when supportive measures are discontinued Ethics in science and medicine I979; 6/i: 59-64. that death becomes imminent. Discontinuing such (3) Proceedings, AMA House of Delegates. December measures is, unavoidably, a 'hastening ofthe hour of 1973. Cited by Steinbock B. The intentional death' (35). It also, unavoidably, requires the temiination of life. See reference (2): 70. shouldering of moral responsibility for the death of (4) See reference (2): 69. (5) Sacred Congregation for the Doctrine of the Faith. the patient. Declaration on euthanasia May 5. Vatican City: This brings me to my second point: the extra- Polyglot Press, I980. ordinary means criterion hides this responsibility (6) See Fletcher J. The rights to live and to die. In: under the mantle of its means-related language. Kohl M, ed. Beneficient euthanasia. Buffalo, New While it may well be true that the doctor has, in York: Prometheus, I979; 47. Extraordinary means and the sanctity of life 79 J Med Ethics: first published as 10.1136/jme.7.2.74 on 1 June 1981. Downloaded from

(7) See, for example Rachels J. Active and passive (3I) See for example, Gustafson J M. Mongolism, euthanasia. The New England journal of medicine parental desires and the right to life. Perspectives in I975 January 9; 292: 78-80, and critique by biology and medicine I973; I6: 529-557. Steinbock B. The intentional termination of life. (32) Colen B D. Karen Ann Quinlan: living and dying in See reference (2): 69-77. the age ofeternal life. Los Angeles: Nash, I976; II5, (8) See reference (5): 6. as cited by Steinbock B. See reference (2); 73. (g) ChiefRabbi Jakobovits I, as cited by John, Cardinal (33) Duff R S, Campbell A G M. Moral and ethical Heenan, Archbishop of Westminster. A fascinating dilemmas in the special care nursery. See reference story. In: Lack S, Lamerton R, Chapman G, eds. (26): 890 (italics added). The hour of our death: a record ofthe conference on (34) Case study 14. In: Beauchamp T L, Childress J F. the care ofthe dying held in London I973. London, Principles of biomedical ethics. See reference (i8): 1974; 7. 263-264. (io) Declaration on euthanasia. See reference (5): 7. (35) See reference (5): II. (ii) Karnofsky D A. Why prolong the life of a patient (36) Morison R S. Death- process or event ? Science I97I with advanced cancer? Cancerjournalfor clinicians August 2o; I73: 697. I960 Jan-Feb, X: 9, as cited by Wilson J B. Death (37) I owe this example to Beauchamp T L, Childress by decision. Philadelphia: The Westminster Press, J F. See reference (I8): I2I. 1975; ii8. (I2) Cameron C S The truth about cancer. Prentice Hall, 1976: 115-I i6, as cited by Wilson J B. See reference Commentary (I I). (13) See New York Times I974 June i6: Part IV: 7, as Gerard Hughes SJ Heythrop College, University of cited by Singer P. Practical ethics. Cambridge: London Cambridge University Press, 1979; 149 and 229. (I4) See Rachels J. Euthanasia, killing and letting die. It would be difficult to read Helga Kuhse's paper In: Ethical issues relating to life and death. New York and remain convinced that all was well with the and Oxford: Oxford University Press, 1979; 150, on arguments in medical ethics about the preservation the practice of 'no coding'. of life, or that the guidelines for medical practice (I5) See Melbourne Herald I979 November 29, reporting were perfectly clear. Her case for saying that there on the death of a squash champion who had are both philosophical difficulties and practical suffered severe brain damage following cardiac is surely unanswerable. Upon closer arrests. 'The machine, in the Royal Adelaide uncertainties Hospital's intensive care unit, was switched off just inspection, however, it becomes less obvious after midnight and Torsam Khan, 27, was dead precisely which points she has established, which a within I0 minutes'. more traditional moralist would be concerned to http://jme.bmj.com/ (i6) See reference (5): II. dispute. Ms Kuhse makes several points: one is that (17) See reference (9): 6 - italics in original. there is a serious inconsistency in the traditional (i8) Beauchamp T L, Childress J F. Principles in view of the sanctity of life; the second is that the biomedical ethics. New York: Oxford University distinction between actions and omissions has no Press, I979; 117-I26. application in the traditional view; and the third (I9) Pius XII, AAS 49. I957; I031-I032. concerns a more positive proposal to replace the (20) Kelly S J G. Medico-moral problems. St Louis, The traditional doctrine about the sanctity of life by a Catholic Hospital Association, 1958; 129. fully explicit appeal to the quality of life. I should on September 25, 2021 by guest. Protected copyright. (21) See reference (5): 10. like to reply, as it were on behalf of the traditional (22) See reference (2): 72. position, on each of these points, and to make some (23) In the matter of Karen Quinlan. Opinion in the remarks on precisely how they are connected to one Supreme Court of New Jersey 1976 March 31. another. 355 A. 2d 647, p 659. Helga Kuhse argues that it is inconsistent to hold (24) McCormick R. The quality of life, the sanctity of both the 'sanctity of life doctrine' and the view that life. Hastings Center Report 1978; 8/i: 30. there is an important distinction to be drawn (25) See reference (5): 6. between ordinary and extraordinary means of (26) See for example Shaw A. Dilemmas of 'informed to consent' in children. The New England journal of preserving life. Now, it certainly is inconsistent medicine 1973; 289: 885-890. Also Duff R S, hold both: Campbell A G M. Moral and ethical dilemmas in a) that one must never intentionally kill, shorten life, the special care nursery. The New England journal or allow someone to die, and ofmedicine I973; 289: 890-894. to take means (27) Crane D. The sanctity of social life: physicians' b) that one is not obliged extraordinary treatment of critically ill patients. New York: to preserve someone's life, Russell Sage Foundation, I975. c) just ifit is also held that the prohibition on allowing (28) See also ReichWT. Qualityoflife. In: Encyclopaedia someone to die obliges one to take all possible means of Bioethics Volume 2 New York and London: to keep him alive. MacMillan and The Free Press, 1978; 831. (29) McCormick R A. See reference (24): 35. The charge of inconsistency crucially depends on (30) See reference (2): 73-74. showing that the 'sanctity of life doctrine' must