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PHI 237 NOTES - Coggle Diagram

- - - - Bouvia: cerebral palsy; forced treatment; quality of life, suicidal (VPE)
      - Quinlan: vegetative (PVS), catholic: remove respiration, protective order; patient right to choose (NPE)
      - Cruzan: PVS; parents feeding tube removal; clear evidence; definitions (NPE)
  - - - Dworkin: Philosophers brief; cant outright ban PAS; Theoretical: PAS improper/proper, Practical: PAS abuses
      - Washington v Gluck: limited PAS; due process; 14th amendment
      - Vacco v Quill: 14th; equal protection; right to end; violates EP; denied PAS not medical right; rght to VPE not PAS
- - - - Action
        
        Action = fully non-controlled if influence is failed or failed relevancy
        
        Not all influences are attempts to control
        
        Action controlled if get controlled agent to do the action
      - Subjective
        
        tried to manipulate if one works but not the other
        
        manipulation failed = not relevant to patient autonomy action
      - Objective
        
        Did a person do a manipulative thing
    - - Persuasion: allornothing; never undermines autonomy; facilitates autonomous choicemaking; influence via appeal to reason; successful influence; secret persuation is not but is manipulation
      - Manipulation: continuum; grey area; maybe undermine autonomy; treatment I prefer is what they should go for first; witholding information; alternatives unfavorable
      - Coercion: allornothing; undermines autonomy; influence person by credible threat; cant resist reaction to threat
      - Hard paternalism: im doctor, i tell you whats best; persuasion
      - Soft paternalism: tell patient what could be the best decision; persuasion
    - - Authentic choice = representative of patients judgement
      - Authenticity not relevant to autonomy of choices/acts; if relevant, decisions (intentional,understood) would fail autonomy
      - Weaken authenticity: if choice is (out of character) then can demote autonomous actions; problem: people do (out of character) things for good reason (skydiving)
      - Non-repudiation: performs action but consciously rejects (wish they hadn't gotten vacinated); fails authenticity and autonomy
- - - - patient choice must be completely their own; autonomous to meet standard of informed consent
      - protect patients from outside influence (family/religious memebers)
    - - Must disclose nature/purpose; risk/benefit; probability of success; alternatives; prognosis without treatment
        
        Reasonable Person Standard: (average person) disclose information relevant to decision about treatment; court cases
        
        Subjective standard: disclose what is relevant in specific context; patient may have preference/circumstances which require disclosure (concert pianist)
        
        Professional Standard: What other docs would disclose; determine degree of disclosure required
    - - Must be capable decision-maker (no disorder/ kids)
    - - Disclose info in a way that a patient can comprehend what you're saying
    - - consent not needed for emergency, incapacity, waiver, therapeutic privilage
  - - - good intentions towards patient; make choice for them; assumes doctor has knowledge/moral/legal authority
      - Knowledge: patient may have different values
      - Authority: not doctor place to substitute judgement unless patient is globally compromised decision-making(needs evidence)
- - - - Introducing lethal agent to patient
      - Voluntary: give the lethal injection
      - Involuntary: leave them alone; doctor gives lethal injection anyway
      - Non-Voluntary: not competent patient (disorder, young, injury); written statement of conditions (competent); don't keep alive
    - - Withholding/ withdrawing life sustaining treatment; if we dont do something, patient will die
      - Voluntary: they want to die
      - Involuntary: decision maker want patients treatment to be continued; incapacitated patient; take them off anyway
      - Non-Voluntary: not competent patient (disorder, young, injury) decision maker remove from life support
    - - Doctor gives (competent) patient tools to end their own life
- - - - Life: Born with cerebral palsy; quadripalegic; immobile besides face, fingers; severe arthritis; pain
      - What happened: Mentally competent; intelligent; Riverside, CA; wanted to die by starvation; feeding tube forced; bit through; 4 orderlies forced gastronasal tube; against will
    - - patient right to refuse; 1983 lower court ruled hospital does have right; 1986 appeal court rejected: has right to make decision of treatment
      - Decision: Quality of life important; patient should make value judgement; removing treatment is not positive death inducing instrument but positive life inducing treatment
      - Conclusion: Won court case; chose to live; couldnt endure starvation; morphine made starvation worse; wanted to die of natural causes
  - - - Life: 21yr; not eaten for 2 days; party; drinks and valium; stopped breathing; unconscious; brain hypoxia (no oxygen); brain damage; vegetative state (would never be conscious again)
      - Parents want disconnect respiration not feeding tube; Catholic: breathing for someone = extraordinary care not morally required; feeding someone = ordinary care morally required
    - - Decision: Hospital was threatened with homicide charge if respirator disconnected; hospital + Quinlans request protective order allow resp removal; 1975 trial court refused; 1976 Supreme court reversed: patient right to choose
      - Conclusion: hospital wean off respirator; breathe on own; lived for 9 years; 1985 died respiratory failure
  - - - Life: 1983 car accident; face down puddle of water; severe hypoxia; medics: no vital signs; 3w went in coma; vegetative state (not going to wake up = PVS); feeding tube; 5yrs; parents feeding tube removal; hospital refused;
    - - Decision: Parents won; Nancy would have wanted; told a friend she wouldn't want to be kept alive; appeal to supreme court Missouri; reversed decision: parents do have right but need clear evidence;
      - Conclusion: Missouri ruled: have right but need clear and convincing evidence; friend not sufficient; not taken off treatment; Appealed to Supreme court; claimed Due Process clause 14th amendment; ruling violated due process unjustified legal barrier of Nancy's liberties; 5-4 upheld ruling
      - Definitions
        
        Standard of proof: must prove right to win
        
        Preponderance of evidence: 50% + a feather; civil suit
        
        Clear and convincing evidence: twice as likely to not be correct (2:1)
        
        Beyond a reasonable doubt: no alternative explanation exists; criminal suit
        
        Law of land: need explicit written directive of what should be done; can force to keep alive against will
        
        Living will: legal document detailing treatment when no longer competent
      - Conclusion: Missouri withdrew objection; had met standard; 1990 removed
- - - - Family outlook: doctor shouldn't play god; how so when god stopped her heart; she would not be better off dead; removing life support = moral decay society; a miracle could happen;
      - Treatment history: futile treatment: doctor will not continue ventilator; case goes to court; medicare= 200k, private insurance 500k; feb-may 91', another facility all refusal;
      - Life: 85yr; jan 1,90' respirator discomfort; wean from respirtator cause heart to stop; unconscious; may 31, 90' doc wants to remove respirator; another facility 2w shes vegetable; doc wants to end treatment; family declines
    - - Decision: hospital request: impartial custodian to represent helga interest; treatment could be ended without liability from custodian; july 1, 91'; husband custodian hospital gave up; 3d helga dies multiple organ failure
    - - Begs the question: argument assertion of what you're trying to prove (bible)
  - - - Life: thanatophoric dysplasia: dwarfism; respirator after birth; recovery impossible;
    - - mother Wanda refused; strange belief: the sun is babies father; refuses psych; competent; contacted 40 facilities none willing; ventilator removed: Texas advanced directives act (Futile Care Law not real);
      - Texas only state for Involuntary passive euth (IPE) allowed; NY (not allowed); Sun sedated, taken off respirator, died asphyxiation a minute later
      - Texas ADA: IPE doctor treatment not useful other than continuation of life; judgement reviewed by ethics comittee; proxy decision maker (provided alt facilities to contact); 10d treatment can be ended
- - - - Theoretical: if decriminalize PAS (pain), how draw line proper/improper
        
        Qualify this general principle: states have consti right to override peoples decisions when (a) irrevocable, (b) interference would later be appreciated by person interfered with
        
        Formulate a general principle: competent people have right to make decisions for self
        
        both support right of states to regulate PAS but incompatible with blanket bans
      - Practical: if PAS allowed, impossible to prevent abuses (vulnerable populations)
        
        1) poor might be better with legal PAS (suffer till die), rich can get illegal PAS,
        
        2) Legal PAS make decisions might be less appealing (affordable pain meds), if legal hospital proof of best medical care before PAS
  - - - limited access to PAS 14th amendment (liberty interest) (due process clause: cannot deprive person life, liberty or property without due process of the law.) greater interest = greater justification government must take
      - Glucksburg argued citizen should have right to own death
      - Slippery slope: PAS could undermine trust doctor; PAS lead to coercion on poor,elderly; legal PAS lead to legal VAE or IAE
    - - Argued 14th amendment guarantees all citizens equal protection under the law
      - Quill argued terminal patients = right to end life via VPE, w/PAS non terminal dont have same right (treatment wittheld until starvation or dehydration kills) violates Equal Protection clause 14th.
    - - Court overturn appellate; states right to blanket prohibitions on PAS; denies Due Process right to PAS because not extended to help from medical professional, denies violation Equal Protection clause because everyone has right to VPE, not right to PAS
- - - - Active euth (PAS) allowed if doctor is satisfied (pain and not improving; no reasonable alternative); possible legal case (falls in category if disorder) (6,585 psysical:83)
- - - - Diane end life by PAS; PAS illegal all 50 states; Quill never prosecuted; Quill tried to get PAS legalized nationwide
    - - Life: 45yr; 8yr doctor of hers; vaginal cancer; depression; abnormal bloodwork; acute leukemia; agressive treatment (pain and monetary) 25% survival, alt 0%
      - Does not want treatment; angry; understood diagnosis; prep for hospice care at home;
      - Request: wants prescription for suicide; refers to Hemlock society; 1wk request barbiturates(essential for hemlock) for insomnia; talk in person; doc gave prescription; healthy for months; medically shes great;
      - Decline: 3m dreadfully sick; pain; schedule times to talk; 2d after seeing Quill she died at peace on couch; medical examiner cause of death was acute leukemia; no mention of barbiturates; helped indirectly make death possible
- - - - Autonomy: allowing VAE; end-of-life decision is personal and belongs to them
      - Well being: only known through observation; difficult to know what is best for someone else; secures beneficence; value judgement; justice is distribution of desired treatments (is there enough?)
      - Against VAE
        
        AE is deliberate killing of human being/morally wrong; reply: PE is not always permissible (killing vs letting die not good distinction) they're both letting someone die
        
        People have a right to not be killed; VAE violates that; reply: rights can be waived by holder of right (competent and informed) (have right to car)
        
        Slippery slope worry
        
        VAE will lead to Non-voluntary AE
      - VAE ILLEGAL with Morally Permissible
        
        Bad consequences of legal outweigh good
        
        Good consequences: # cases; VAE can relieve stress; end painful conditions
        
        Bad consequences: goes against morals; against committment to optimal care; VAE can be a kind of harm; once an option it is a harm; slippery slope to wrongful cases (bad patient)
        
        Brock perspective: highly speculative; claims are weak