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Extraordinary Means and the Sanctity of Life

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Extraordinary Means and the Sanctity of Life 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.
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