Avoidance of Killing - Case Study in Pharmacy Ethics (Veatch).pdf

Avoidance of Killing 135

Killing is a complex and ambiguous term. Some people imply that the word always conveys a negative moral judgment—that to say something is a killing is to say it is morally wrong. However, we sometimes speak of justifi ed killings, such as in cases of justifi ed war, police actions, self-defense, and perhaps merciful euthanasia. There are many ways in which society, both secular and religious, has condoned the taking of another person’s life, some of these against that person’s will. The wide prevalence of the death penalty, ethnic cleansing, jihads, and even assassinations makes clear that throughout history humans have believed that killing can be justifi ed.

It seems that not all behavior that is causally related to the shortening of life is classiﬁ ed as killing. For example, as we show in this chapter, most people do not con-sider refusing life support to be a suicide and, in some cases, withdrawal of another person’s life support is not considered a killing, even though such refusals and with-drawals will lead to death. Moreover, even if an action is deemed to be a killing, the use of that term does not automatically imply that the action is morally wrong. For example, accidental killings, such as from a lethal idiosyncratic reaction to a pre-scription, are not always morally wrong.

Even among actions that are directly intended to terminate the life of another, we can distinguish killing for merciful motive from other kinds of killing. We can also distinguish self-killing (suicide) from the killing of another (homicide). We can distinguish killing with the consent of the one killed from those that are invol-untary (against the victim’s wishes) and those that are nonvolinvol-untary (without the approval or disapproval of the one who is killed). Finally, we can distinguish homi-cide on request (in which the health provider or other acquaintance of the patient will kill on the patient’s request) from assisted suicide (in which the health provider supplies information or materials (such as medication) but patients themselves take the last decisive step in ending their own lives).

Our traditional religious and secular values have dictated that even in cases in which the motive is merciful and the patient requests the action, it is wrong to kill.

But why? If the killing relieves severe suffering, especially if it is requested by a com-petent patient, can it not count as a good and noble thing to help those who are suffering end it?

We have seen that some people hold that in ethics the consequences are the only morally relevant factor. Utilitarians, for example, hold this view. So do those who subscribe to the Hippocratic principle, which requires the health professional to always act only so as to beneﬁ t the patient. Although many health providers do not realize it, the Hippocratic principle by itself could permit or even require the health provider to cooperate in killing a patient when it would, on balance, do more good than harm.

However, the Hippocratic Oath also contains a speciﬁ c provision that is usually interpreted as prohibiting active killing. Technically it proscribes “giving a deadly drug, even if asked.” But usually in modern readings that is taken to prohibit gener-ally any physician participation in killing. Insofar as the oath can be extended to all health professionals, it would prohibit pharmacists from participating as well. Since most pharmacists are not normally in positions where they would seriously contem-plate mercifully killing patients on their own, the codes of pharmacists generally do

not mention a prohibition on killing, but one can assume that such actions would be opposed by the traditional pharmacist organizations. In fact, as we see in the cases in this chapter, pharmacists do actually encounter situations where they are asked to participate in forgoing treatment and some are now actually placed in positions where they could consider whether to cooperate in an assisted suicide.

The interesting problem is why such a prohibition on killing exists if the goal of the provider is always to beneﬁ t the patient. One possibility, of course, would be that the authors of the oath considered it always a net harm to the patient to end the patient’s life. Many people, however, are willing to concede that, at least in rare cases, the patient may be worse off if he or she continues to live. Normally, that would involve cases of intractable, severe suffering. If some patients occasionally would actually be “better off dead,” then there are two other possible justiﬁ cations for proscribing merciful killings.

First, as we have seen in previous chapters, some people who base moral judg-ments on consequences do not believe it is right to directly calculate the consequences in each individual case. Instead they consider possible alternative moral rules or poli-cies. They assess the net consequences of the alternative rules or policies and choose the rule or policy that they believe will do more good than any alternative. These people are called rule-utilitarians.¹

They may do this for a number of reasons. First, some are worried about the risk of error if individuals were permitted to make the calculations on the spot for each case. Especially in highly emotionally charged situations where rapid decisions have to be made and especially when those doing the calculating may not know the individuals affected very well, the danger of miscalculation may be great. These crit-ics of merciful killing believe that in the long run more good may be done (and more harm prevented) if we simply apply the rule against killing because on balance it will produce more good than any alternative.

Second, some people, not necessarily persuaded that the risk of error is this great, may still hold that it is just the nature of morality that practices are established by evaluating alternative rules or policies and choosing the set that produces the greatest net good.² They may favor a rule against merciful killing because they con-sider it the utility-maximizing rule, that is, they may believe that the rule prohibiting such killing produces more good outcomes than any other rule they can imagine. For either of these reasons, some consequentialists, those who are rule-consequentialists, may favor a rule that prohibits health professionals from participating in killing.

There is a second reason why the Hippocratic Oath may prohibit active killings for mercy. As we have seen in previous chapters, there may be moral principles other than beneﬁ cence and nonmaleﬁ cence that determine whether an act is right or wrong.

We have already seen that some people hold that autonomy, veracity, and ﬁ delity to promises help determine the rightness of actions regardless of the consequences. Is it possible that killing is just inherently wrong—even if the one who is killed is better off than if he or she had lived? If so, avoidance of killing could be an independent prin-ciple that helps shape the rightness and wrongness of human conduct. We might refer to it simply as the principle of avoidance of killing. It is not clear whether the writer of the Hippocratic Oath believed this. If so, he was not a pure consequentialist.

Avoidance of Killing 137

Whether the Hippocratic author believed that killing people was inherently wrong, clearly other moral traditions are committed to this view. Judaism considers life to be sacred, a gift from God. Killing a human, at least an innocent human, is always wrong. In fact, Judaism has even gone beyond the view that killing, at least killing of the innocent, is wrong to the view that all human life is sacred. According to this perspective, it is always wrong for humans to make decisions, such as decid-ing to withdraw life support, which will predictably shorten a patient’s life.

Catholicism considers killing an intrinsic wrong, but, as we shall see, this tradi-tion does not extend its condemnatradi-tion to all actradi-tions that will shorten life. It accepts certain forgoing of life support. Other moral traditions, both religious and secular, condemn killing as well.³ They at least view it as prima facie wrong, that is, wrong insofar as the action involves killing (although that wrongness might, on occasion, be offset by other moral considerations). If killing is always a wrong-making char-acteristic of an action, then avoidance of killing can be thought of as another moral principle that must hold beneﬁ cence and nonmaleﬁ cence in check.⁴ The cases in this chapter help clarify how pharmacists should evaluate possible attempts to relieve patients of their misery by putting them to death. In later sections of the chapter, participation in active merciful killing will be compared and contrasted with decisions to forgo treatment (to withhold or withdraw treatment).

Active Killing Versus Letting One Die

Both religious and secular traditions in the West have held that it is always mor-ally wrong to actively kill a human being, even if the killing is done for a merciful motive. For example, some terminally ill patients appear to be in pain. They may be inevitably dying rapidly and could be spared the misery of the dying if someone actively intervened with an injection of a drug to hasten death. Some argue that such intervention would be the humane and moral thing to do, but others claim that there is something intrinsically wrong with killing—that life is sacred and to be preserved or that at least it should not be ended directly by human hand. The fol-lowing case, ﬁ ctionalized, but based on real events in several states, raises the ques-tion of whether there is any signiﬁ cant moral difference between actively killing someone who is dying and simply stepping aside and letting nature take its course.

CASE 9-1 Prescriptions for Suicide: Forming a Policy for Pharmacy

Eun Peet, Pharm.D., had breathed a sigh of relief when the state’s newly passed ballot measure allowing citizens the option of assisted suicide (in the form of a prescription for a lethal dose of a drug) was not allowed to go into effect because of legal challenges.

Dr. Peet was the current chair of a liaison committee representing all pharmacy organiza-tions in the state. She had the unenviable task of sitting through endless debates on the bill trying to reach consensus. The APhA Code of Ethics for Pharmacists wasn’t a great deal of help in this area. There was no statement in the code prohibiting active killing or assisted suicide. There was also no statement or position paper in pharmacy publicly stating the

CASE 9-1 Continued.

profession’s position as there was in the American Nurses Association and the American Medical Association. The American Society of Health-System Pharmacists Statement on pharmacist’s decision-making and assisted suicide allowed each pharmacist to make his or her own decision about whether or not to participate in assisted suicide.⁵

Now that the ballot measure was in legal limbo, Dr. Peet hoped that the liaison group could explore just what the pharmacist’s role in assisted suicide might be should the law go into effect. There were certainly practical and procedural concerns regarding the law even by those who supported it. The means of assisting in the suicide outlined in the law was a prescription for a lethal dose of medication or combination of medications. Although phar-macists are capable of recommending proper therapeutic doses of medications, would they be able to determine what dosage would be lethal for a particular patient? Would they be expected to counsel patients on how to properly take their medications so that death, not permanent injury, was the outcome? These practical questions were almost eclipsed by the comments of opponents of the law concerning the inherent wrongness of being involved in any way with active killing or assisting in suicide. Members of the liaison committee who opposed active killing and assisted suicide were not appeased by the con-science clause in the law that allowed pharmacists the right to refuse to participate. The opponents of the law wanted the liaison committee to issue a clear statement that the collective voice of pharmacy, at least in this state, opposed the law.

The reprieve that Dr. Peet thought she would have to wrestle with these divergent views turned out to be short-lived when she opened the morning paper and read that the state supreme court would not block the law. The legal barriers that delayed the implementation of the law appeared to be gone. Dr. Peet knew that her phone would start to ring any moment with questions about the pharmacy profession’s position either for or against the law.

CASE 9-2 Deciding Whether to Fill a Lethal Prescription

Although the so-called death with dignity law legalizing assisted suicide had been in place for a year, this was the ﬁ rst time that Moe Jamison, Pharm.D., had actually received a lethal prescription from a terminally ill patient. Dr. Jamison actually knew the prescription was coming since the patient’s physician had called earlier in the day to talk with Dr. Jamison about his recommendations for the most effective combination of drugs to result in certain death. Dr. Jamison believed that a person had the right to choose his or her own manner of death and that there should be laws to legalize medication for assisted suicide.

He also believed that pharmacists should have a role in advising the prescriber on the choice and dose of drugs used. Furthermore, he thought it was essential that pharmacists be informed about the intended purpose of prescriptions for assisted suicide so that they could decide whether to participate in dispensing or not.

Now that he was holding the prescription in his hand and could see the slender, frail patient waiting on the other side of the counter, Dr. Jamison wasn’t certain he could take this last step and dispense the medication for assisted suicide and counsel the patient on its appropriate use.

Avoidance of Killing 139

Commentary

Dr. Peet is facing a problem that many pharmacists may have to face as soon as assisted suicide becomes legalized either by court order or by statute. The writers of these proposals seem to worry about granting physicians the right to conscientiously refuse to participate, but there is real doubt whether pharmacists and other health care team members also have that right. Traditionally, it is a moral, and perhaps a legal, duty for a pharmacist to ﬁ ll a valid prescription. It is an open question whether a pharmacist may refuse on grounds of conscience. Dr. Peet is being asked to for-mulate a position on behalf of the pharmacy organizations in her state regarding pharmacist participation in assisted suicide through the act of ﬁ lling a valid and legal prescription.

The ﬁ rst issue raised is whether this is a matter about which pharmacists can and should speak with one voice. Is there a single view on such controversial matters that should be held by all pharmacists? Is there a practice of pharmacy to which all pharmacists should subscribe that must either include or exclude ﬁ lling such prescrip-tions? One possibility here is that pharmacists of Dr. Peet’s state will simply agree that there is more than one possible answer to such controversial questions, that either participation or refusal would be acceptable, as in the case in the ASHP state-ment on assisted suicide. This is another way of saying that there may be more than one acceptable conception of the practice of pharmacy and that the state pharmacy coalition should not enter into taking a position on exactly which conception of the practice is best.

Even so, Dr. Peet and the other pharmacists of the state will have to decide what they can do ethically when presented with such prescriptions. One issue pharmacists must face is both conceptual and moral. Is there a signiﬁ cant difference between active killing for mercy when the killing is done by another on the request of a patient (homicide on request) and assisted suicide, in which the patient kills himself or herself with the help of another?

Some are claiming that a line can be drawn between the two. They may be point-ing to the concern that homicide on request sometimes raises the issue of whether the homicide was really requested by the patient and, if so, whether the patient was competent when the request was made. There is concern that such actions would be open to serious abuse, as it would be hard to verify that the request was truly voluntary since the patient will be dead by the time the question arises.

Others, however, say that even in the case of assisted suicide the patient could be forced, pressured, or manipulated into taking the lethal medication. In any case, they claim, even if there are pragmatic differences having to do with degree of certainty that the request from the patient was actually made, there is no difference in principle between homicide on request and assisted suicide. In both, the patient would not die but for an action of someone else. That action is a decisive event in the causal chain leading to the patient’s death. They say that if one is wrong, then the other is as well.

One approach to these issues focuses on the consequences. Some would approach the question in traditional Hippocratic fashion by insisting that the pharmacist’s moral duty is to beneﬁ t the patient. Then the question becomes one of whether it is ever possible to beneﬁ t someone by killing them or by helping them kill themselves.

Defenders of active killing, including physician-assisted suicide, claim that killing does no harm in such cases and may actually prevent future harm (that is, patient suffering).

They argue that, if the active intervention shortens the period of suffering, it may actu-ally be moractu-ally preferred over simply stepping back and letting the patient die.

Critics of such practices also raise arguments based on consequences. They claim that the consequences of a policy authorizing active killing may be different from those of a policy that accepts the forgoing of life-sustaining treatment. Some of these critics are what in the introduction we called rule-utilitarians. They believe that moral-ity is based on certain practices or rules, and they assess the consequences of general rules rather than those related to speciﬁ c choices in individual cases. They believe that even if Dr. Peet or a colleague can correctly determine the consequences in a particular case, the risk of abuse of a policy endorsing active killing is too great. They

In document Case Study in Pharmacy Ethics (Veatch).pdf (Page 155-178)