AUTONOMY AND EUTHANASIA: THE IMPORTANCE OF THE CULTURAL CONTEXT

Authors: Anneliese Dörr, Psychologist M. Elena Gorostegui, Psychologist

Introduction

Euthanasia and its bioethics-related variants have come into the limelight in recent years, as a result of widely publicized cases that have moved public opinion, such as the case of Vincent Humbert in France, that of Terry Schiavo in the USA, not to mention Ramón San Pedro in Spain, which also gives food for thought about this matter. They are probably not the only cases and will not be the last, but they will be studied for some time as real applications in the fields of Bioethics, law, humanism and religion.

Starting with a brief historical overview of Bioethics, this paper reflects on the principle of Autonomy and some of its implications in the area of troublesome ethics that arise daily in medical practice, in this case, Euthanasia.

Considering that Bioethics is a relatively new discipline, in practice it is possible to find cases where the overly strict application of basic principles might prove to be harmful both to the patient and to his family. Thus, there are cases, for example concerning autonomy, in which concrete praxis, that is, the application of the principle, enters in conflict with the essentialness on which it is based. It is not an isolated fact that the theoretical principles enter in conflict with the empirical realities to which they apply. The key is to try to make the application of the principles incorporate the critical spirit as opposed to abstract notions that, although well meaning, may be too rigid to be applied to real cases.

1. Fundamental Philosophers of Bioethics

According to the Spanish philosopher Ortega y Gasset, values are extremely subtle realities, so much so that they are almost evanescent in comparison with other realities that are more evident and trustworthy, namely facts, which we understand to encompass all that directly or indirectly is perceived through the senses and remains evident to perception (Ortega y Gasset, en: Gracia, D., 1995).

The ethical dimension in the human being is a topic that has concerned philosophers since the beginning of time. Aristotle, in his work Ethics to Nicomaco, postulates that moral virtue is a halfway point between what one should and what one should not do, except for those sins that can always be considered evil. In other words, Aristotle’s idea of the virtuous man was one who exercises prudence in order to achieve happiness, applying his qualities neither lavishly nor meanly. Aristotelian ethics begin with a requirement to perfect oneself in the sense of overcoming one’s own weaknesses and focusing on good, that is, moving towards self-fulfillment. In this sense, the man who acts in accordance with his own conscience is living ethically.

Lately, there has been a reawakening of the so-called Ethic of Virtues of Aristotle, in the hypothesis of A. Mac Intyre.(1987). Mac Intyre offers a contemporary vision of virtues and maintains that social practices like medicine, for example, evolve generating both external and internal good. By external good he means the social retribution for job performance, like prestige and honor; by internal good he means the practices that depend on the honesty with which one works, namely dignity, respect and responsibility. Medical ethics are a part of the internal dimension, which makes Medicine a moral profession, that is, a practice oriented towards good.

Emmanuel Kant has also had a substantial influence on the study of the moralethical dimension of man. This philosopher, in the eighteenth century with his work

Criticism of Practical Reason, postulates the existence of universal moral principles that state one must do good and avoid evil, and attempts to determine ethical principles by means of rational procedures. Moral principle has some validity for everybody, thus Kant’s concept of morality stems from the rejection of principles that cannot be applied to everybody uniformly, and therefore it is one’s reason and not subjective impulses that guide human action. In this sense, moral conscience is related to will, which is by its very nature human, and thus with freedom and once again with the idea of autonomy. According to Kant, right, the origin of duty, is autonomous, that is, it emanates from individual autonomy; thus the origin of morality is not intersubjective but subjective. (D. Gracia, 2004),

Ethical judgment can be found within mental faculties; therefore one can conclude that the only unquestionable good is the goodwill of men, which is expressed in an ethical way of behaving. In this way, the human being must look for the motivation of his acts in an imperative, in an obligation that is so general that it may as well be universal, that is, always unconditionally true. Being absolute, the imperative sought receives the name categorical imperative, and consists of acting in accordance with a norm that could be accepted as a universal maximum.

According to Kant, ethical behavior is based on an absolute duty on which a series of duties depend that are related to circumstances, which the philosopher terms hypothetical imperatives. For example, the imperative “do not lie” may have some exceptions when trying to save someone’s life or avoid greater damage.

Both Kant’s ethics and the Ethic of Virtues reflect on the phenomenon of morality as a whole, using methods and terminology associated with philosophy. The use of the term Deontology refers to those streams that postulate that behavior obeys a priori mandate that cannot be questioned; an example of this is Kantian theory. By contrast, the Aristotelian teleological approach proposes that ethics are evaluated based on a result, that is, they are oriented towards an end. Thus, Aristotle

believed that before making an ethically correct decision, one must assess the consequences and they are paramount in determining the course of action. The Hippocratic Oath is the oldest evidence in our culture of ethical concern in the practice of Medicine. However, it was the doctor Thomas Percival who in the nineteenth century coined the phrase medical ethics and has as a result been named the father of medical ethics. In the same century, the Medical Deontology codes appeared, which purport to make a detailed list of the requirements both legal and medical in the practice of the medical profession. (Gafo, J., 2003). Since that time, the terms medical ethics and morality have frequently been used.

2. Birth and Development of Bioethics

The term Bioethics as we know it today arose in the United States in 1974 as a result of outcries over the use of human beings in experiments. That year, the National Commission for the Study of Ethical Dilemmas was created; the result was the Belmont Report (Gafo, J., 2003). This report set out objective ethical principles representative of the pluralistic society that is America. It finally identified three fundamental principles: autonomy or respect for persons, beneficence and justice. The principle of autonomy is based on the conviction that the human being must be free from external control and be respected in his basic life decisions. The second, the beneficence principle, also includes an obligation to not do evil, and third, that of justice, is applied from the perspective of distributive justice.

The Belmont Report was approved in 1978 and published in 1979. That year saw the publication of the work of Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics (Gafo, J. 1993), which elaborates on the principles stated in the National Commission and that would be important in the later development of Bioethics. From this work arose the theory called Principle-ism, which gives general principles a central position in the approach to bioethical problems. One these general principles were determined, they came to make up the source and foundations of other more specific rules.

T.L. Beauchamp and J.F. Childress,(1999), interpreting the Belmont Report, consider that the principle of non-evil is independent of beneficence, since the duty to not hurt the sick person (non-evil) is more obligatory and imperative than that of promoting the patient’s wellbeing (beneficence). The principle of non-evil is the primary ethical requirement that the physician not utilize his knowledge or his situation of power over the patient to do him harm. This principle is present in the Hippocratic Oath (“above all, do no harm”) and has been at the core of classic medical ethics. This is a perfect obligation, which requires an impartial fulfillment when applied to any person. Nevertheless, beneficence enables the doctor to favor persons with whom he has a special relationship, that is, it is an imperfect obligation, in the sense that one can demand it of oneself without others demanding it. According to the above quoted authors, for the beneficence principle to be obligatory there must be a cost benefit calculation. Even in the United States, this principle is in doubt because of its inherent paternalist component, which leads one to convert a patient into a dependent entity, almost stripping him of his adulthood. This principle is criticized because of the danger of it being applied without the patient’s consent, that is, without him accepting the good that others want to do for him. That is why we speak nowadays of the beneficence principle 2, which means taking into account the autonomy of the patient.

In any case, these four principles (autonomy, beneficence, non-evil, justice) are readily acceptable by all members of a community, however pluralistic it may be, and are considered prima facie duties, that is, when they do not enter into conflict with each other, they are morally binding. Which of the principles rules over the others will depend on the consequences and that is why ultimately the Beauchamp and Childress system is consequence-oriented. ( Gracia, D., 1995)

3. Differences between the Anglo-Saxon (English-speaking countries whose citizens are mainly of British descent) and continental European perspectives in their approach to bioethical dilemmas

Even when principles are defined that any society can accept and share from a theoretical point of view, the perspective of analysis and the orientation of thinking changes according to the societies at the time of proceeding and putting the principles into practice. Thus, there are substantial differences in the field of bioethical decisions between the Anglo-Saxon continental European steams. (Patrao Neves, 1996). A clear example of the differences in how shared principles can be interpreted and applied is found in the ways reproduction techniques and transplants are handled. In the Anglo-Saxon countries, foremost is the principle of autonomy over and above respect for the dignity of man. This explains why in the United States there are no limits to access to reproduction techniques and why the rights of the newborn are relatively more limited, for example, not being able to learn the identity of one’s biological parent. By contrast, in continental Europe the anonymity of the donor is not considered sacrosanct. The same applies to the regulation of embryos, a field in which continental Europeans exercise greater control that the Anglo-Saxon countries.

Thus, we see that European societies uphold the principle of solidarity, that is, justice, which means that not only is the privacy of field data important, for example regarding genetic engineering, but also the possibility that society could have a similar chance to reap the benefits.

In summary, the American perspective is more individualistic than that of continental Europe; it is more concerned with micro-problems, that is, those issues that require immediate solution, than macro-problems, in which the moral interests of the entire group are involved. Thus, the bioethical perspective of Europeans is considered to be very identified with man’s concern or social dimension, with more emphasis on the principles of justice and fairness than on each individual’s rights. (Patrao Neves, 1996).

According to Patrao Neves, the explanation given to these variations is that there are differences between the philosophical traditions of Anglo-Saxon and

continental European societies. He states that Americans have more of a pragmatic and Utilitarian perspective, where results of actions are considered to determine their moral status (Empiricism of Francis Bacon and Utilitarianism of J. Bentham), while continental Europeans are marked by Rationalism (the phenomenology of Husserl and Existentialism of Jaspers). This leads Europeans to have a bioethical perspective of social orientation and makes them particularly sensitive to questions of fairness.

It is for this same reason that continental European tradition believes it possible to establish absolute principles that impose a moral obligation regardless of the subject’s will (deontological) On the other hand, American ethics are teleological, that is, determined by the consequences. They start from the Utilitarian premise that the basic moral obligation is to achieve the greatest good possible for all, or at least for the majority. This is how they understand the beneficence principle: promoting good. Since good is not the same for everybody, they postulate that the beneficence principle is inseparable from that of autonomy. Therefore, in teleological ethics, absolute priority is given to the combination of autonomy and beneficence, in which the end is to be always the greatest good possible, with each person concerned having a say in what is good. (Gracia, D. 1999).

4. Analysis of ethical conflicts from the point of view of Diego Gracia

Diego Gracia (1995), tries to resolve the debate of whether there are absolute ethical principles with precedence over the empirical autonomy of persons, based on the premise of what is known as minimal ethics. This concept arose in Gemany during the Third Reich, when Theodor W. Adorno wrote his book entitled Minimal Morality about the autonomy-beneficence combination, to address the fact that the model of society apparently preferred by the majority of the German population at that time would be considered immoral by other peoples. He stated that there

should exist a minimum level of morality, below which immorality would rule regardless of what everybody accepted.

Applying these ideas to the field of Bioethics, Diego Gracia stated that these moral minimums were: the principle of non-evil and the principle of justice, which are an expression of the general principle that all men are equal and deserve equal consideration and respect. These principles are binding regardless of the will of the persons concerned, and in case of conflict the common good has priority over the interests of the individual. In summary, the four principles are classified in the following two hierarchical levels:

Level 1, made up of the principles of justice and non-evil, which correspond to minimal ethics. Level 2, made up of the principles of autonomy and beneficence, which correspond to maximum ethics (dependent on the moral values of each person).

Faced with ethical conflicts, the author states that the principles themselves do not solve moral problems a priori; these principles must by definition be general, while ethical conflicts are particular and concrete. Thus, in the process of ethical reasoning, there are two moments:

a) Principle-ist or deontological, where principles are established a priori b) Consequence-oriented or teleological, in which the particular situation is taken into account; this is an experiential and a posteriori approach. This second moment corresponds to phronesis or Aristotelian prudence.

For its part, one of the most important characteristics of phronesis was having to take into consideration the consequences of the actions or the decision.

This appears very enlightening to us when we reflect on the topic of euthanasia, so in fashion in recent times.

5. Bioethics and Euthanasia

The principle of autonomy (critical for reflection on euthanasia) is based on three main ideas: a) Treating persons as autonomous agents, and b) Watching over the rights of persons whose autonomy is diminished. c) The person is an end in himself and never a means to any other thing (Kant)

From these convictions we deduce two moral obligations from the Belmont Report: a) Recognition of the autonomy of the other, and b) Protection of persons whose autonomy is impaired.

The most concrete and immediate consequence of the principle of autonomy for the patient is expressed in the so-called informed consent, as a regulating pillar of the relationship between health care professionals and the patient.

In American Bioethics, there is a strong emphasis on this ethical principle, undoubtedly as a result of the characteristics of United States culture. Thus, in the inevitable tension arising between the principle of autonomy and that of beneficence, the patient’s autonomy tends to get more preference. In this sense, it is important to take into account that Beauchamp and Childress tried to solve this problem by depicting the principle of autonomy as inseparable from that of beneficence, given that good cannot be done without considering the autonomy of persons, that is, that what is good for some may be bad for others.

Nevertheless, this principle in the case of Euthanasia can be considered to contradict itself or at least poses a paradox, because in many cases treating people as autonomous agents, and at the same time watching over the rights of those persons whose autonomy has been jeopardized, cannot be achieved.

The reflection on euthanasia comes to be a topic of fundamental importance for today’s Bioethics in terms of the application of the principles to the framework of applied ethics. In this sense, it is important to note the contribution of Adela Cortina of the Universidad de Valencia. The author points out that as a result of globalization, people with diverse moral conceptions live together in societies with wide-ranging outlooks on life and personal happiness. She states that the people in such societies have “moral minimums” and “moral maximums”. The “minimums” are related to the regulation of the state, and involve least common denominators like not killing or stealing, etc. The maximums, however, are those morals that are adopted: religion, positions on euthanasia or cloning, contraceptive medication and others. (Adela Cortina, 2003)

In the monist societies (for example, Muslim countries), there are only moral maximums that are imposed on an entire population and are not discussed, but in pluralist countries minimums coexist with maximums in a constant dialogue, and therefore this reflection on euthanasia becomes possible. The level of maximums is expressed in the principles of autonomy and beneficence, and it is here that legitimate differences arise; each person can configure his existential project according to his own ideals. From an ethical perspective, they are imperfect duties, since they pursue a particular good. Nowadays these concepts constitute powerful tools to understand the necessary relationship between unity and diversity between person and citizen.

6. Reflection on current cases

Even though it is possible that cases of euthanasia, however we understand the term and whatever degree of intervention constitutes euthanasia, for various reasons some cases have become notorious possibly due exclusively to their journalistic coverage. Some examples are Vincent Humbert in France, and more recently, Terry Schiavo in the USA.

6.1 The V. Humbert Case

In the case of the young Frenchman V. Humbert, his mother gave him a lethal injection of barbiturates in order to cause his death, though she failed to achieve this because the amount injected was not enough. As a result, his doctor decided to finish what his mother had begun and put the young man out of his misery. The patient had explicitly begged for help in ending his life, meaning that to a certain extent the actions of the mother and doctor respected the principle of autonomy. This young man, quadriplegic as a result of an accident, wrote the following to President Chirac: "Mr. Chirac: My name is Vincent Humbert, I am 21 years old, and I suffered a car accident on September 24, 2000. I was in a coma for nine months, and am now in the hospital. All my vital senses have been affected, except for my hearing and intelligence. I can barely move my right hand by pressing with my thumb on each good letter of the alphabet. These letters make up words, which in turn make sentences. It is the only way I can communicate. I have decided to write to you because you have the right of clemency and I ask you for the right to die.” With these words, the young quadriplegic fireman, mute and almost blind, implored the French President for the right to active euthanasia, since he was unable to die by his own hand. But this was illegal in France, so the Head of State merely responded, “Recover your joy of life! That is an order from the President of the Republic ". That was when he decided to end his life at all costs; Vincent managed to persuade his mother, Marie Humbert, to administer him a lethal injection of barbiturates. This was three years after the accident. However, the inadequate dose injected by his mother failed to put an end to his suffering and merely cast him into a deep coma. After consulting his medical team, the head of the hospital revival team, Doctor Frédéric Chaussoy, decided to disconnect him from the machine that was keeping him alive and injected him again. Vincent passed away in September 2003. The same day he died, his book I Ask For the Right to Die.

This case filled the pagers of the newspapers and moved French society. At the same time, it rekindled the debate on euthanasia in that country, since not only Marie Humbert but also Dr. Chaussoy were being tried for it rekindled the debate on euthanasia in that country, since both Marie Humbert and Dr. Chaussoy are on trial for administration of toxic substances to a vulnerable person, with premeditated intent and premeditated poisoning, for which they could be sentenced to five years in prison or life imprisonment, respectively. Because of Vincent’s case, the Ley Vincent Humbert Act was passed, which does not try to legalize Euthanasia but to introduce an exception in the penal code to contribute actively to help put an end to the life of a terminally patient, but also that of any mentally or physically disabled person suffering so much that he does not consider life to be worth living. . The lower house of the French Parliament approved the bill which, without actually legalizing euthanasia, makes it permissible to leave patients to die if they have no hope of being cured or are in the terminal phase and have consistently over time expressed their desire to stop living. This bill, although it does not amend the Criminal Code, does seek to enshrine in the Code of Public Health the doctor’s duty to respect the patient’s will, overcoming the irrational stubbornness of providing certain medical treatments in irrecoverable terminal cases, and fight against suffering. It stipulates that if the patient is unconscious, medical attention should not be continued when it is pointless, disproportionate or if it serves only to prolong life artificially. It gives the doctor and the family the power to disconnect the patient or speed up his death through medication if he so desires. The law creates a right to die in order not only to enhance the rights of patients but also to provide legal protection to physicians, threatened by prison sentences of up to 30 years, if they deliberately cause the death of a sick person, even at the patient’s request. According to the Minister of Health, Philippe Douste-Blazy, this law is “neither status quo nor outright euthanasia”. The patient will be able to reject continuing a

treatment, but will not be able, for example, to order a doctor to give him a lethal injection. This advanced document, accepted both by the churches and by the Human Rights Commission and by the Academy of Medicine, provides a third way, the so called French way. Currently euthanasia is legal only in the Netherlands and Belgium, while Switzerland allows people to help patients commit suicide.

6.2 The Terri Schiavo Case

The second case is more recent and involves the husband of American Terri Schiavo who, when she was in a vegetable state 15 years after suffering a heart attack caused by a strict diet, filed a suit to be allowed to cut off his wife’s supply of food and water and thereby put an end to her life.

In 1990, Terri, then 26 years old, suffered a heart attack (apparently as a result of a weight loss treatment program), which cut off the flow of blood to her brain for about five minutes, causing a permanent damage. Two years later, her husband won a million dollars in a medical negligence suit, $700,000 of which was spent on Terri’s medical care. In 1998, Michael Schiavo asked for his wife9s food supply to be cut off, alleging that she had indicated she wanted this done before lapsing into the vegetable state in which she remained for several years. One week later, the Florida legislature approved the Terri Act, which gives the Governor of the state the authority to reconnect the tubes.

From that time, October 15, 2003, the topic caught the interest of the press and became a news item, at the same time as numerous appeals were being allowed, including one to the Supreme Court, in which the parents and siblings were involved in an unsuccessful campaign to keep Terri alive. Nevertheless, on March 31, 2005, the feeding tube was removed from Terri and she died 13 days later, at the age of 41, 15 years after lapsing into the coma.

In the case of Terri, the decision of the American courts caused conflict, as the patient’s situation was unclear. Although the ethical principles of autonomy and non-evil prohibit extraordinary measures to keep the patient alive when he shows no signs of recovering consciousness, in this case she was practically left to die of starvation and dehydration. Terri was in an unprotected state and her autonomy jeopardized when the decision was made to stop feeding her. Thus it was possible to violate this principle even though the patient not only was not terminally ill, was not connected to an artificial respirator, and was not receiving parental feeding, but also had never expressed her desire to die, at least not explicitly.

In this case the autonomy principle enters in contradiction with itself, since in its name the patient is left to die, but to achieve this end the autonomy principle must also be violated. That is, on the one hand the patient has not expressed her desire to end her life, and on the other hand, also in the name of the autonomy principle, the decision is made to cut off her food and water. That is, based on the premise of upholding the autonomy of those persons whose autonomy is impaired and thus cannot decide for themselves. Here supposedly the aim is to prevent the patient from continuing to suffer in her present state and enable her to rest in peace, by ceasing to assist her. But the right of a person whose autonomy is diminished is not safeguarded. What happened in this case? How is it that physicians are ordered by law to violate the principle of non-evil, that is, never do harm (considering that sick people in total fast end up with cardiac atrophy)?; what can we take as the fairest and most appropriate ethical and moral limit?

Final Considerations

In the two cases of euthanasia presented above, the Anglo-Saxon bioethical tradition is illustrated (the Terri Schiavo case) with results that are questionable, to put it mildly. On the other hand, the Humbert case illustrates the tradition, in Europe, essentially in France, in which after long debates and reflections at least a partial solution has been reached, which helps to meet the need for laws to

regulate the application of the principle, in the concrete situation and at the specific time that the latter are enforced, if their enforcement requires special considerations.

In the specific case of euthanasia, there are no two equal cases (ethic of maximums), therefore it is very hard to reach a consensus. This is why it becomes so difficult to draw the line and distinguish between a person who helps another under the principle of beneficence and autonomy, from another person who, weighing given considerations, acts to harm. In addition, it is curious that Americans, for whom the autonomy principle is absolutely fundamental, do not manage to create laws that govern the enforcement of this principle, which should assess the concrete situation and the right time for the laws to be enforced. Regarding the Terri Schiavo case, the Code of Ethics in Chile prohibits physicians from supplying drugs or medication that cause death and at the same time from using excessive measures on a patient whose death is imminent. It is precisely in the issue of feeding that the Chilean Code of Ethics and the World Medical Association differ from the regulations governing American medicine, since in the USA, artificial supply of food and water are included as extraordinary measures. That is, the Schiavo case could not have arisen in our country.

Upon hearing the news of the death of Terri Schiavo, the Chilean College of Medicine issued a declaration emphasizing the “right of every person to die with dignity”. It is not clear what would have happened here in a case similar to that of the young Frenchman.

The variety and complexity of concrete situations arising from the possibility of prolonging the end of a person’s life points out the need to review in each case the validity of the application of bioethical principles that appear unquestionable and, even more so, the vital contradiction that their application can imply.

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