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May 04, 2006

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Is refusing to rescue someone drowning in a puddle not murder? If the drowner is already dying of cancer?

Just a useless link for hilzoy.

I am struck by the family's phrase that Andrea should die naturally. Isn't that what's being prevented by medical treatment?
I don't mean to be critical of her family. It really isn't clear any moe when a death is natural and when it isn't. My grandmother died naturally I suppose after my dad told the hospital to stop treating her for anything but pain. She was unconscious and had pnuemonia. She was also over ninety.

Is refusing to rescue someone drowning in a puddle not murder? yes, it is not murder. There is NO duty to come to the aid of another except in limited circumstances.

Should have specified "not in legal terms".

Well, but what if they tripped on your foot? On your off-leash dog?

Anyway, I think if there were a universal ethic it would treat shooting someone and not rescuing them from a puddle as nearly equivalent.

It really isn't clear any moe when a death is natural and when it isn't.
I once said to a friend, as we discussed this very question, that the only 'natural' way to die is being taken down by wolves when you can't keep up with the rest of your tribe. It's harsh, but we have to remember that medicine is all about preventing things that would normally kill us from doing so. As our capabilities grow, this inevitably raises questions. Hilzoy laid them out quite eloquently, but the 'Let someone die naturally' has never struck me as terribly compelling.

rilkefan: I don't think it's murder in non-legal terms. Or at least: it's not murder to come to the aid of someone whose life you can save. If it were, then every dime we spend on anything not strictly necessary for the preservation of our own lives would be murdering one of the people whose lives we could save by sending it (with the other dimes) to Oxfam. I have pretty serious views about obligations to give to charity, but they don't go that far.

Besides, it's disanalogous in all sorts of ways. Competence, for one.

Here's a different case: suppose you get some horrible disease that renders you (a) incompetent to choose (suppose sever brain damage), (b) in serious pain, and (c) terminal -- you have, at best, a few months. Suppose further that you have left no advance directive, and your wishes are unknown. Finally, suppose that you get some illness that would kill you more quickly if not treated -- say, pneumonia. Is it murder not to treat you?

'severe', not 'sever', brain damage.

'sever' brain damage would be 'severe' by definition, no? Fatal, even.

Unless it's on Star Trek, and Dr. McCoy hasn't forgotten the so-simple-a-child-could-do-it brain-reconnection technique.

"'sever' brain damage would be 'severe' by definition, no? Fatal, even."

For humans, maybe, but not all species. See Ringworld for a counterexample.

IANABioethicist, but FWIW I'll point out that pneumonia long had the nickname "the old man's friend," and that, in practice, doctors and families quite often DO make the conscious decision to take action to end lives sooner than they might otherwise end by increasing dosages of IV morphine provided to treat pain to the point of fatal respiratory depression.

The implications for me are that the boundary between action and inaction, when it comes to medical treatment that, as noted upthread, is all about NOT allowing people to "die naturally," is thin indeed, and to my mind matters far less than consideration of possible outcomes (including both benefits and costs) of possible courses of action. Along those lines, not pulling someone out of a puddle, which would save a life at the cost of a little bit of muscular effort, is morally not far away from outright murder, while not providing expensive or rationed (i.e., nonzero opportunity cost) treatment to a fatally ill patient whose quality and quantity of life thereby would not be extended much if at all, thus incurring a certain high cost for an uncertain, limited, and possibly nonexistent benefit, would be much less morally clear.

"If it were, then every dime we spend on anything not strictly necessary for the preservation of our own lives would be murdering one of the people whose lives we could save by sending it (with the other dimes) to Oxfam."

If Oxfam uses the money efficiently, then I think you're wrong, based on my guess at the supposed ultimate ethics. What e.g. would you think from behind the veil of ignorance? I at least don't see an obvious stopping point before radical equality. (Aside: as I understand it the opposite is rather like trickle-down theory.)

In the brain damage scenario, the "severe brain damage" bit suggests to me that "murder" isn't applicable. If Oxfam used my dime to support hydrocephalics, then probably I'd want my dime back.

Hilzoy,

....Finally, suppose that you get some illness that would kill you more quickly if not treated -- say, pneumonia. Is it murder not to treat you?

I want to tentatively answer yes. Suppose that someone has a terminal disease and will die in five years. But then they develop TB now. I’d say it’s impermissible to refuse them treatment for TB now, merely because they’ll likely die of some other disease. For, surely the (likely) medical effectiveness of a procedure is determined by how good it is at curing/alleviating its target ailment in the patient, not how likely it is to make the patient a whole, healthy human being. If so, and if a particular treatment for the TB would be medically effective, it’s impermissible to refuse to carry it out b/c the patient will die anyway.

Now, if in that situation it’d be OK to treat the patient, then why wouldn’t it be OK to treat the patient who’ll die in (5 yrs. – 1day), and so on, to your preferred sorites cut-off point. (So, expected time of death is probably irrelevant.)

Whatever one replaces TB with, either it’ll be curable (at the time) or not. If it’s not curable, then no dilemma. If it is curable, I’m not seeing why the fact that the patient is near death from some other disease makes it impermissible to carry out potentially medically useful procedures etc. So, if one denies treatment for curable ailment A because the patient is going to die anyway from ailment B, one is culpably negligent. But if one’s culpable negligence leads to a reasonably foreseeable death, then that’s some form of culpable killing.

emmanuel g: I was thinking that two crucial facts were the unremitting suffering, combined with the loss of so much mental functioning that that suffering had to be unredeemed. (I think that if I suffer, now, I can alter my suffering by what I make of it. I can turn it into a blessing of some sort, or I can make it more of a curse than it ever had to be. In either case, I give it some meaning above and beyond itself, by what I make of it. But that takes some amount of thinking -- not lots and lots, not the sort you have to be an Einstein to engage in, thinking that's within the grasp of the vast majority of people -- but not thinking that's within the grasp of someone with severe brain damage. So her suffering will be suffering, pure and simple.)

The role of time does matter, at least insofar as the longer someone will live, the less grounds you have for certainty about the outcome. That a child who is born now with Tay-Sachs will die a horrible death after a horrible life is pretty certain. That someone with an incurable illness will die ten years from now, and that no relief will be forthcoming during that period, is a lot less certain, though there are things that could make it more so (e.g,, certain forms of massive damage to the body.)

I am not, of course, denying the Sorites. Still, in most real-life situations, I think that the thing to do with Sorites paradoxes is to recognize that you need to draw a line. This is what we do with drivers' licenses: of course there's nothing magical about a kid's sixteenth birthday (or whatever driving age is today), and of course she's not markedly less likely to be a good driver if we let her start driving one day earlier, or one day before that... etc. But since letting her start driving at birth would be a bad idea, we draw a line.

I am not, of course, denying the Sorites.

I do, but only because I regard the underlying binary logic as inapplicable. [Removing an object from a pile decreases its "pileness" by a fraction and increases its "not-pileness" by a similar fraction; it's just that we tend to regard extremal cases as definitive while casually disregarding the blurry area in the middle.] When we have some external need, e.g. the drawing of a legal line to distinguish a driving age as per your example, we can draw the line as you said, somewhere in the middle where it seems reasonable to do so. As you said, the line's necessarily arbitrary but the key point IMO is to acknowledge 1) precisely that it is arbitrary and 2) that we're drawing this lines for extrinsic reasons, often barely related to the issue at hand before 3) moving on to more important matters.

I'm not entirely sure what this has to do with the topic, but since I've got nothin' on that count anyway...

If this woman genuinely wants treatment, and this is the USA, right? She even pays personally for her treatment (through insurance). No, the hospital is not obliged to give it to her, nor is the insurance company I suppose, that depends on the contract, but if either refuse, prudent people should shun them.

And also, by the same reasoning refusing to save a life is not murder, prolonging a painful life is not torture.

Harold, FWIW, in most of these cases the patients are not able to pay for it, even if they have insurance. Insurance companies have their own criteria and will frequently stop paying for treatment that is futile or with no prospect for improvement of the patient's condition. Exceptions are made for treatment such as hospice, or purely palliative care (pain medications, etc.)

And this brings us back to one of hilzoy's points about appropriate use of resources, including financial, that a treating facility has available.

I think in this case, one of the factors in the facility deciding to keep the patient is that at least one doctor felt that there was reason to believe that the patient may recover, after a thorough examination of the patient.

I, quite simply, am very glad I am not placed in a situation where I would have to make the determinations necessary.

Thanks hilzoy, good explanation of the issues. Wonder if there are not-exactly-hospice, not-exactly-hospital facilities that could handle this sort of case.

The sister's complaint indicated overmedication for pain by the doctor. This is supposedly keeping her sister from being competent. Why doesn't she refuse this treatment? Then her sister would, according to her, become competent to speak for herself. Since "competent" patients will get whatever treatment will prolong their life, why doesn't the sister take action to ensure that this competence can show forth?

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