Cognitive impairment and euthanasia

One of the biggest fears expressed by opponents regarding the legalisation of euthanasia or assisted suicide, is that it would come to be used on those with intellectual disability or cognitive awareness.
  • Doctors and hospitals already make decisions not to treat people who fit certain criteria.
  • Medical staff are making end-of-life decisions based on their perception of a patient's quality - or value - of life.
  • "[Some] adult human patients may genetically be human beings, but they are not human “persons”
  • Bioethicists are attempting to establish a philosophical foundation for denying disabled people the equal protection of the law.
  • "We have to go stage by stage, with the living will, with the power of attorney, with the withdrawal of this..."
Teenager Christopher Campbell had been unconscious for three days because of brain damage following a car accident when he developed a high fever. His father John Campbell asked the nurses to cool his fever. They replied that first they needed a doctor's orders.

Campbell asked them to obtain it, but Christopher's physician was out of town and the on-call doctor said no. "It was an evening of hell," Campbell says. "My son's life meant less than hospital protocol. When the doctor refused to order treatment, the nurses said that there was nothing they could do."

Campbell desperately tried to reach the on-call doctor himself, but the physician refused to take Campbell's phone calls or respond to his increasingly urgent messages. Meanwhile, Christopher's condition worsened steadily, his fever rising over a period of some twenty hours, to 107.6 degrees.

Finally, the nurses — caught between a desperate father's pleas and a doctor's steadfast refusal to treat — insisted that the on-call doctor take Campbell's call.

Campbell demanded that his son's fever be treated immediately. The doctor refused. When Campbell grew more insistent, the doctor actually laughed. The boy was unconscious. His life was effectively over. What was the point?

"By this time," Campbell recalls, "my son's eyes were black as if he had been in a fight. He was utterly still. He was burning up. The back of his neck was so hot you couldn't keep your hand on it. I said to the doctor, 'This is not a joke! This is my son. His life is at stake. His temperature is over 107 and you are going to do something about it."' Hearing the angry determination in Campbell's voice and perhaps fearing legal consequences if Christopher died untreated, the doctor finally acquiesced.

Shortly after treatment commenced, Christopher's temperature subsided. Soon he was moved to a rehabilitation center for therapy and began a slow recovery. Today, he lives at home with his parents where he is learning to walk with assistance.

When not in rehabilitation, Christopher works at a local youth center where he feeds animals and counsels at-risk teenagers. Christopher is very glad to be alive — and his parents and the many troubled people he helps every day are glad, too. 1

This is not an isolated case. More and more, medical staff are making end-of-life decisions based on their perception of a patient's quality, or value, of life. Opponent to euthanasia and assisted suicide (EAS) blame what they see as the 'deterioration of medical ethics' largely on the philosophy of Bioethics, which they see as an off-shoot of eugenics.

Eugenics is the study of methods to improve the human race by controlling reproduction.

Eugenics has had a religious dimension. Julian Huxley, the first Director-General of UNESCO and a member of the English Eugenics Society:

"We must face the fact that now, [...] the great majority of human beings are substandard: they are undernourished, or ill, or condemned to a ceaseless struggle for bare existence; they are imprisoned in ignorance or superstition.

We must see to it that life is no longer a hell paved with unrealized opportunity.... In this light, the highest and most sacred duty of man is seen as the proper utilization of the untapped resources of human beings."

I find myself inevitably driven to use the language of religion. For the fact is that all this does add up to something in the nature of a religion: perhaps one might call it Evolutionary Humanism.

The word religion is often used restrictively to mean belief in gods; but I am not using it in this sense ... I am using it in a broader sense, to denote an overall relation between man and his destiny, and one involving his deepest feelings, including his sense of what is sacred.

In this broad sense, evolutionary humanism, it seems to me, is capable of becoming the germ of a new religion, not necessarily supplanting existing religions but supplementing them." John Cavanaugh-O'Keefe, pro-life activist, researcher and writer, wrote:

"The Population Council, one of the new eugenic organizations that emerged after World War II, no longer spoke of eugenics as a religion (in fact, avoided the word eugenics altogether), but launched "studies relating to the social, ethical and moral dimensions" of population studies, recognizing that these questions involve matters "of a cultural, moral and spiritual nature."

The new field of bioethics is a response to issues raised by eugenics. Bioethics is based on situation ethics, which was developed largely by Joseph Fletcher. 2
Joseph Fletcher
Fletcher, who died in 1991 was a leading academic involved in the topics of abortion, infanticide, euthanasia, eugenics, and cloning. He served as president of the Euthanasia Society of America (later renamed the Society for the Right to Die) from 1974 to 1976. He was also a member of the American Eugenics Society.

Fletcher dismissed the traditional medical 'reverence for life', claiming that "nobody in his right mind regards life as sacrosanct." Fletcher distinguished "human life" from what he called 'personal life'. "What is critical is personal status," he wrote in 1973, "not merely human status."

Fletcher created a list of criteria or indicators that he hoped could be used to divide society between those individuals who possessed 'humanhood' and those who did not — between 'truly human beings', deserving of great moral concern, and others who were 'subpersonal' and of scant consequence. Fletcher's criteria

In Fletcher's 1975 essay "Being Happy, Being Human" 3 he describes participating in a panel discussion of the treatment of babies born with serious birth defects. A physician who cared for a profoundly mentally retarded boy reported that while possessing a very low IQ, the child was clearly happy and clearly a human being. Fletcher coldly dismissed the human worth of this defenseless child — and many other mentally retarded people:
"Idiots are not, never were, and never will be in any degree responsible [because they cannot understand consequences of action]. Idiots, that is to say, are not human. The problem they pose is not lack of sufficient mind, but of any mind at all. No matter how euphoric their behavior might be, they are outside the pale of human integrity. indeed, sustained and "plateau" euphoria is itself prima facie clinical evidence of mindlessness.4 Such a provocation had a purpose: to gain support for the notion that "idiots" could, depending on the facts of each individual case, ethical and right, and that such decisions, rather than even being morally portentous, were merely a "clinical" matter."5
Anti-euthanasia activist Wesley J. Smith says:
"Once someone like Fletcher secured a beachhead, it was only a matter of time before someone like Peter Singer would stage his much-publicized landing in bioethics. One of the world's most influential contemporary utilitarian bioethicists/moral philosophers, Singer takes Fletcher's original formula and extends it to even more radical ends. Whereas Fletcher sought to determine who had moral value strictly for the benefit of humans, Singer expands the "moral community" into the world of animals."
Peter Singer and 'Personhood'
Although born in Melbourne, Professor Singer has since 1999 been based in the USA where he is Ira W DeCamp Professor of Bioethics at the Centre for Human Values at Princeton University.

Better known for his 'animal liberation' advocacy, Singer and other bioethics writers argue that the higher primates, e.g., dogs, pigs, apes, monkeys, are persons—but that some human beings, e.g., even normal human infants, and disabled human adults, are not persons.

For example, the following list of adult human patients may genetically be human beings, but they are not human “persons”: Alzheimer’s and Parkinson’s patients, the senile, persons with mental illness, the mentally retarded, drug addicts, alcoholics, the comatose, patients with multiple sclerosis, paraplegics, cripples, patients in persistent “vegetative” state, and many more...

Philosopher/bioethicist R.G. Frey has also published that many of the adult human beings on the above list are not "persons," and suggests that they be substituted for the higher primates who are "persons" in purely destructive experimental research. 6

These arguments for “personhood” – i.e. 'individuality', 'rational attributes' or 'sentience' – are based, not on scientific fact but on philosophical grounds.

President of the US disability activist organisation 'Not Dead Yet, Diane Coleman, is concerned that Singer and other bioethicists are attempting to establish a philosophical foundation for denying disabled people the equal protection of the law and "killing us for his version of the greater good.” 7

Non-Voluntary Euthanasia
Non-Voluntary Euthanasia is carried out without the knowledge and/or consent of the person in question. It may also be carried out without the consent and/or knowledge of the person's family, guardian, or someone holding power-of-attorney.

There are numerous cases of people who have been in comas for months or years, diagnosed as brain dead or in a 'persistent vegetative state' (PVS), who have woken and recovered.

One study of patients diagnosed as being in a 'persistent vegetative coma' (ie comatose), showed that 41% had regained consciousness within 6 months, and 58% had regained consciousness within 3 years. A second study of children in comas for over 12 weeks found that 75% eventually regained consciousness. Another study found that 33% pf 370 patients in a 'PVS' for up to a year recovered enough to work.8

Because some patients with a diagnosis of PVS do recover, it is not easy to prove that the condition of the brain in patients diagnosed as PVS, as a class, is such as to rule out the possibility of recovery or awareness in any given case.

However, many people believe that patients in a 'PVS place a strain on limited resources and that physicians who care for them. With health budgets under stress, the deciding factor in whether or not a cognitively impaired person gets to live or die is money.

In the Netherlands and Oregon,in the USA, euthanasia and assisted suicide has more of a connection to economics and healthcare rationing, than patient autonomy.

In the United Kingdom, health care is rationed. For this reason, the National Health Service established the National Institute for Clinical Evidence (N.I.C.E.) now called National Institute for Health and Clinical Excellence (which is still called N.I.C.E.) to issue “clinical guidelines” that blend “efficacy of outcomes, quality of life judgments, and economics”:
An assessment is made of the cost of the treatment per additional year of life which it brings, and per quality adjusted life year (QALY) . . . which takes into consideration the quality of life of the patient during any additional time for which their life will be prolonged. The clinical and cost effectiveness of the treatment under review is then used as the basis for a recommendation as to whether or not . . . the treatment should be provided in the NHS.

These “clinical guidelines” (increasingly imposed by both academia and insurance companies in the United States) sound harmless. After all why would anybody wish to “prolong” the lives of people who are terminally ill or whose quality of life is otherwise very poor? The problem has to do with just who gets to define what level of “quality” is meaningful, in permitting the disabled to live.9
The 'wedge principle'
Euthanasia and assisted suicide legislation almost invariably start as 'voluntary' with numerous criteria built in to such Bills/Acts as 'safeguards'. Opponents claim that the initial 'safeguards' are, in reality, the thin end of the wedge that will enable activists to challenge the Law through the Courts.

While euthanasia advocates dismiss such claims, opponents point out how the same thing happened in regard to abortion. Under New Zealand law abortion is still a crime except when a woman meets certain strict conditions. The abortion criteria was to make abortion a rare occurrance and "have regard to the rights of the unborn child".

In reality, it is openly acknowledged that abortion-on-demand exists in New Zealand. In response to the situation of doctors breaking the law, the Abortion Supervisory Committee's recommendation is to decriminalise abortion so that doctors can offer abortion-on-demand without having to lie about it.10

Writers Susan and Robert Sassone point out:
"Practically every advocate of euthanasia at one time or another has said or written, that the best strategy for euthanasia is to first have passed into law those measures which encounter the least resistance, then to extend the principle of euthanasia by a gradual series of steps until they get what they want." 11
For example:
"We have to go stage by stage, with the living will, with the power of attorney, with the withdrawal of this; we have to go stage by stage. Your side would call that the 'slippery slope'.... We would say, proceed with caution; learning as we go along how to handle this very sensitive situation.'" - Derek Humphry 12
  1. John Campbell, interview with author, 29 April 1999.
  2. John Cavanaugh-O'Keefe, Introduction to Eugenics
  3. Joseph Fletcher, "Being Happy, Being Human," The Humanist 35, no. 1 (January 1975), pp. 47-58, as republished in Humanhood
  4. Ibid., p. 22
  5. Ibid., p. 20
  6. R.G. Frey, "The ethics of the search for benefits: Animal experimentation in medicine," in Raanan Gillon (ed.), Principles of Health Care Ethics (New York: John Wiley & Sons, 1994), pp. 1067-1075
  7. Not Dead Yet
  8. Andrews K. "Managing the persistent vegetative state:. Minnesota Physician Jan.1989, p.5. Lisa Fitterman. "Neurologist Has Cautionary Tale for Euthanasia Fans." Vancouver Sun [Canada], 8 Sept 1993, p.B3
  9. Being N.I.C.E. to “Useless Eaters”
  10. Abortion Supervisory Committee and Controversy in New Zealand
  11. S & M Sassone. Handbook on Euthanasiap.105, 536.
  12. Derek Humphry, Director of the Hemlock Society, quoted in a December 18, 1986 interview.