Thursday, October 3, 2013

Ethics Essay - "Killing" vs. "Letting Die"

In the second year here at MSU CHM, we take an ethics course for the first half of the first semester. This mostly involves reading ethics articles, writing ethics papers, and talking everything over. I don't know whether or not most med schools do this kind of thing, but I'm willing to bet that the places which have an Ethics class aren't quite as in depth with it as CHM. We're split into small groups of 6-8 students per group, and each group has a preceptor, usually a clinician. We meet only once per week for two hours. The class only lasts eight weeks. During those eight weeks, we have to write at least five of the eight possible "Weekly Essays." The topics are prescribed, and the grades for these essays comprise the bulk of the course grade. My understanding is that the course isn't really designed to be difficult to pass, but it's more designed to make you think about things from different perspectives, gaining an understanding of what clinical ethics is along the way.

This week, the essay took its springing point from one of our online lectures, which outlined an argument for claiming that there is an important difference between "killing" and "letting die":

“Killing is an action, where directly causing the death is the goal of the action. Letting die is a failure to
act, where the resulting death is not the primary goal.” Construct an argument that shows either that 1) this is not a defining difference between “killing” and “letting die”; or 2) that it is not an ethically important difference; or both. (Critical reasoning) 

I gave it a whirl, and it wasn't the easiest paper to write, since for the most part I agree with the prompting statement. A lot of old-school physicians would probably agree wholeheartedly with the idea that there's no difference between killing someone and letting them die. This was actually the opinion of a doctor we saw in a video from the 70s who refused for more than a year to allow a total-body-burn victim to refuse treatment and die. That doctor very clearly said that by allowing his patient to refuse treatment and die rather than doing the procedures of which he was capable, he would effectively be murdering his patient. He never considered the concept, as explained by the interview with his patient in the same video, that there are worse things to experience than death. There's a big difference in culture between medicine today and medicine 40 years ago. Back then, doctors more regularly had greater power to do everything they could to save a patient than we do today. Patient autonomy is much more highly valued in today's medical culture than it was a while ago. SO, I tried to write my article as though it were from the viewpoint of that old-school physician. 

Regardless, I constantly felt like my essay was full of holes even as I was writing it - holes that, if I were actually arguing against what I was writing, I would gladly exploit. I think this was the point of the experience, since given that most doctors have to "let die" all the time, most doctors would probably agree that there is an ethically important difference between that and "killing." Anyway, here is the essay I ended up turning in. I'm really not looking for comments on this post - this is more for my recollection years from now about what kinds of things we did in Ethics class. :)


            To discuss whether or not there is an ethically important difference between “killing” and “letting die” based on the proposed concepts that “Killing is an action, where directly causing death is the goal of the action. Letting die is a failure to act, where the resulting death is not the primary goal,” we must first define two concepts. First, the concept of an “action,” and second, the concept of what defines an “ethically important difference.”
            I propose that an individual’s “action” is any operational course taken by that individual with the expressed or unexpressed intent to bring about any single or multiple consequences. Of utmost importance is the concept that a choice by an individual to subscribe to a course of inaction also constitutes a course of action.
I also propose that we define an “ethically important difference” as one that is in line with Lo’s definition of clinical ethics. Lo states that “[w]e use the term ethics to refer to judgments about what is right or wrong and worthy of praise or blame.” (Lo, Ch. 1). The context of this statement by Lo is one of judgment about what is right or wrong in a moral setting – not one of clinical correctness. As such, an “ethically important difference” must be one that differentiates between operational courses in a manner that allows their categorization by intention as either morally right or morally wrong.
            In applying the above rationale regarding ethically important differences to a proposed operational course, the morality of intention of that operational course must be carefully considered. The morality of the operational course is determined by the goals motivating the selection and implementation of that course, and whether those goals are right or wrong. Here is where a key factor enters into the equation. The goals motivating a rational and capacitated individual’s selection and implementation of a particular course of action will include both the direct and indirect effects of that action. As rational beings capable of gauging cause-and-effect, intellectually capacitated human beings are capable of assessing the intended primary and a reasonable number of the subsequent “ripple” effects of their actions. That is, with careful consideration, most humans are able to recognize the direct and most indirect outcomes of their actions.
            In the context of this argument, I argue that (as rational, intellectually capacitated human beings) physicians are capable of conceptualizing both the direct and indirect effects of a given potential course of action. Thus, both the direct and indirect effects of a potential course of action must be factored into that which constitutes the physician’s goals, or intentions, as he or she selects among various proposed operational courses. Additionally, any action that is intended to cause the direct or indirect death of another individual must be termed immoral. By Lo’s definition of clinical ethics, any action in this way deemed immoral must be of ethical significance.
            Having established these definitions and logical relationships, I return to the discussion at hand. I have shown that choosing a course of inaction in essence constitutes choosing a specific course of action. I have also made the case that, for a rational and intellectually capacitated individual, the motivation behind any course of action must include the intended outcomes, both direct and indirect, of that course of action. Just because a foreseeable outcome of an action is indirect in nature does not exclude that action from possible moral and ethical consideration. Thus, if the death of another individual is an intended, indirect result of action, then that action is considered immoral and, by Lo’s definition, of ethical significance.
There is no “ethically important difference” between “killing” and “letting die” in the context of the statements that “Killing is an action, where directly causing death is the goal of the action. Letting die is a failure to act, where the resulting death is not the primary goal.” By choosing to act via inaction in a way that intentionally results in death effectively equates “letting die” to “killing.” In such a context, the only difference between these two terms is one of spelling and semantics. Ethically, there is no difference between them. They are both courses of operation that intentionally result in death.

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