PHLB09 – lecture 4
Short to medium answers in full sentences and paragraph
Comprehension, recall arguments, assumptions authors take
Recall an article
Understand readings and lecture arguments
Look at questions at the back of each chapter to get an idea
Agent Self-determination and Decision-Making
The interests of others: ―What About the Family‖?
Definitions and concepts
Withholding and Withdrawal of Life-Sustaining Treatment
Voluntary Active Euthanasia
John Hardwig: “What About the Family?”
Many medical decisions dramatically affect the lives of family members, but bioethics tends to
focus solely on the interests of the patient. Why?
Medical decisions involve life/death matters?
Preoccupation with biophysical model of disease?
We consider only the medical related consequences of treatment?
Weakness and special vulnerability of the ill?
Often, the patient‘s family is equally affected as the patient‘s (ex. treatment might cost
too much, significant others might have to assume a caregiver role)
We focus on the patient because the patient is ill and it‘s them who‘ll live or die
Focusing solely on ―benevolence‖ toward the patient, and respecting the ―autonomy‖ of the patient,
overlooks significant interests of the family
Instead the medical and nonmedical interests of the patient and family ought should be
(Sure competing interests of patient may often outweigh family interests)
Reconceptualizing the physician and patient relationship:
Ethical role of the physician: impartial advisor
Is this possible? Or is the role of the physician unique? (Physicians are often
unfamiliar with patients and their families, and are trained to pursue medical interests,
not as family advocates).
Hardwig says that the doctor has multiple obligations to both the family and patient,
but has to pay a little more attention to the vulnerable patient – and try to counsel
Ex. son was about to go to university, but the father suddenly decides to go to art school. Hardwig says
it‘s an immoral decision because his decision will impact his son‘s life.
Insofar as we hold that person to an ethical standard, that this was a selfish, not well thought out
decision, morally culpable – moreover the son should‘ve had an active role in the decision-
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Ethical role of the patient: Patient autonomy involves moral responsibility
Autonomy involves the ―responsible‖ use of one‘s freedom
―Confronting patients with tough ethical choices might be part and parcel of treating them with
respect as fully competent adults‖ (78).
If patients cannot shoulder the responsibility, then we should shift away from ‗ethic of
Basically, patient autonomy = patient responsibility = understanding moral rules and engaging
in a moral community = being able to engage in moral decision making if patient able to do
that, then must be respected as a moral agent
―…even if the patient were completely fair in making the decision, the autonomy of the other family
members would have been systematically undercut by the fact that the patient alone decided‖ (79).
Treatment decisions affecting the family require the participation of all family members
Ex. if treatment extends life for 5 years, but needs a caregiver, a university-bound child
might have to put off university to take assume a caregiver role – should be involved in
If there‘s a will/inheritance, then there may be a conflict of interest
People might have different values, which may result in internal family conflict (ex.
person finds that they‘re 4 month pregnant, but test shows genetic defect, she wants an
abortion, but her mother is religious, wants to be a grandmother, and against abortion)
Pragmatic question: does 5 family member‘s opinions override the patient‘s or does
the family‘s opinion matter but the patient has final say… if it‘s like that, then nothing
will be accomplished in a timely manner.
Pragmatic problem: decision-making with everyone takes too much time,
more conflict (ex. needs aggressive chemo treatment, but family takes too long
to decide, may be too late)
One virtue of Hardwig‘s argument was that it‘s the moral process that enables everyone to participate,
in a democratic sense – here‘s a principle of justice, autonomy, moral standard – so we take all moral
agents seriously in the decision-making.
Hardwig‘s opinion was that the patient might feel at ease because family is with them in the
It may be considered utilitarian in that we take a holistic opinion that optimizes and benefits
everyone. [But not really]
Objections: it may not be proper for medical decision-making. It‘s not up to physicians to
ensure moral patients – it‘s not the physician‘s role/responsibility.
If family gives informed refusal/consent. Do we take that as equally as the patient‘s?
Hardwig‘s model… we respect moral autonomy and decision-making, we respect moral
opinions of other moral agents.
Ex. a man was in a motorcycle accident, sister had to move back to take care of him.
Years later surgery may allow him to ride a motorcycle, sister doesn‘t want this.
Should her wishes be taken as seriously? How do we determine who should be
involved n this decision? (Ex. ex-wife because there‘s no other close family?)
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Might have conflicting underlying values. Ex. Jehovah‘s witness wants blood
transfusion but family objects, patient eventually goes along with it.
How do we negotiate religious wishes of family that might conflict?
Ex. Dex‘s case – Dex was a burn victim who rejected treatment, but mom
wanted him to live for religious salvation.
Benefits and burdens
Physical, emotional, spiritual, and financial
Patient and family
―Death with Dignity‖ (Ancient Greeks ―euthanasia‖ meant ―good death‖)
Physician assisted suicide
Euthanasia: active and passive
Patient takes the necessary measures to intentionally take his/her own life
Legal in Canada since 1972
Justification based on respect for autonomy
―Voluntary suicide by a patient committed with the assistance of her physician, who typically
provides the means to end the patient‘s life such as a prescription for a legal does of medicine‖
Illegal in Canada
Objections usually appeal to worries about a ―slippery-slope‖ and dangers of coercion
Moral and legal controversies?
If patient requests suicide, is the doctor obligated to report it?
Depends on how significant the threat is in the doctor‘s opinion
Patient takes the last act to bring own death, physician helps.
―The use, for merciful reasons, of direct actions that result in a patient‘s death, such as giving
the patient a lethal injection‖ (191)
Illegal in Canada (legal in Netherlands and Belgium in 2002)
Moral and legal controversies
Objections generally based on
Beliefs about the social harm caused by the permissibility of ―killing‖
Sanctity of human life arguments
Not protecting life
Beliefs about the physicians obligation of nonmaleficence
Medicine condones killing, worries of loss of trust between physicians & patient
Worries about a slippery-slope and dangers of coercion
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When does it mean merciful? Patient may or may not be competent.
Doctor takes the last act to bring patient’s death. (Ex. patient may be incapacitated)