Ending Life in the ICU: The Vacuity of Sanctity

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In a recent issue of Critical Care Medicine, Curtis and Tonelli (1) correctly point out that physician-assisted suicide (PAS) and voluntary euthanasia (VE) are rarely relevant in the ICU. What is relevant though, and interestingly unanimously rejected by Goligher et al (2), is what they define as non-VE (NVE); the patient neither consents nor objects to euthanasia because of decisional incapacity. Yet, for proponents of the position that there is no ethically meaningful difference between PAS/VE and withholding/withdrawal of life-sustaining therapy (WWSLT), this rejection seems untenable. The reason is that nonvoluntary WWSLT often occurs in the ICU for patients who do not have decisional capacity and no advance directives, based on substituted judgment and/or best interest considerations. It is these same considerations that would ground the permissibility of NVE.
This is a nonissue for those accepting a substantive ethical difference between physician-assisted death (PAD) and WWSLT. This difference rests on two core concepts, the sanctity of human life and the fundamental moral valence of intention. A debate that seeks consensus in the first three questions posed by Goligher et al (2) can be achieved if these two concepts are addressed in terms of the strength of reasons against PAD they provide. The sanctity of human life can be understood either as an implication of religious beliefs or in two secularly minded ways. The first relates to Dworkin’s contention that this impersonal value derives primarily from the investment that has been made in a human life. As McMahan though points out, applicable to ICU patients appropriately considered for WWSLT, the persons’ death would not involve a waste of investment, because the investment is already either realized or doomed to frustration (3). The second notion derives from the Kantian concept of dignity, a kind of supreme value requiring that we must always treat rational beings as ends. In order to treat a rational being as an end, we must respect its autonomous decision-making, including decisions that rule against prolongation of life. These two secular ways of understanding the sanctity of life do not provide conclusive reasons against PAD. It is then often in religious beliefs (explicit and covert) that the defense of sanctity is based; nevertheless, these beliefs cannot offer reasons to people who do not share them.
Finally, intention and the doctrine of double effect are argued to offer moral justification for WWSLT in opposition to PAD. At a first look though, and less importantly, it seems mysterious to both argue that we can have no knowledge of the goodness or badness of death and that death is a harm; only if death is indeed a harm, we cannot morally and/or prudentially intend it. It is more significant though to highlight that the same intention ought driving both WWSLT and PAD, and that is the relief of suffering and the liberation from unwanted artificial means of support. For patients receiving optimal palliative care who may not achieve these goals unless they die, PAD not only is ethically justifiable but morally required.
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