 On behalf of the McLean Center for Medical Ethics, I want to welcome you to today's lecture in our series on ethical issues in end-of-life care. Next Wednesday, Professor Alan Meisel, Director of the Center for Bioethics and Health Law at the University of Pittsburgh, will speak on the lack of consensus about futility. I hope you'll be able to attend next week's lecture. Now it is my pleasure to introduce today's speaker, Dr. Daniel Solmacy. Dr. Solmacy is the Kilbride Clinton Professor of Medicine and Ethics in the Department of Medicine and Divinity School at the University of Chicago, where he serves as Associate Director of the McLean Center for Clinical Medical Ethics and as Director of the Program on Medicine and Religion. He has previously held faculty positions at New York Medical College and at Georgetown University. He received his bachelor's and medical degrees from Cornell University, completed his residency and postdoctoral fellowship in general internal medicine at Johns Hopkins Hospital and holds a PhD in philosophy from Georgetown University. He has served on numerous governmental advisory committees and was appointed to the Presidential Commission for the study of bioethical issues by President Obama in 2010. His research interests encompass both theoretical and empirical investigations of the ethics of end-of-life decision-making, ethics, education, and spirituality in medicine. He has published extensively and serves as Editor-in-Chief of the Journal of Theoretical Medicine and Bioethics. Today, Dr. Solmacy will speak on voluntary stopping, eating, and drinking, separating the wheat from the chaff. Please join me in giving a warm welcome to Dr. Daniel Solmacy. Thanks for the introduction. Thanks to all of you for coming. I guess no profit is without honor, except in his native land. I see we switched from La Petite Follie to Potbelly for my lecture. Anyway, I'm going to talk to you about, as Monica suggested, about voluntarily stopping, eating, and drinking. Some preliminaries about this. This is in contrast to a lot of other talks in this series. This is more of a work in progress. Basically it was outlined on the plane to San Diego and the slides were made on the way back from San Diego and there's no text yet, so I'm looking for feedback. The topic is controversial. Certainly we're doing some controversial ones, probably this one, more so. Rather than a sort of overview of the issues, I'm going to try to give you a sustained, ethical argument. Despite the fact that the really hot button issue underneath all of this is questions about the ethics of assisted suicide, I'm going to prescind from any judgment precisely about that question. My aims are to try to define this practice of voluntarily stopping, eating, and drinking for you very carefully. To argue that VSED, as it's even called in the literature, is actually a form of suicide and that for a physician to assist a patient with voluntarily stopping, eating, and drinking is a form then of physician assisted suicide and therefore the conditional argument is that if a physician assisted suicide is wrong, then physician assistance with voluntary stopping, eating, and drinking is also wrong. So it's a simple logical framework to the argument. I think that careful answers to questions like this require from us some careful thinking. Maybe it'll be too heavy for you to do while you're having lunch. I hope that's not the case. I'm going to try to be clear to you about what my assumptions are. Try to work towards some definitions. Talk about what it means to be complicit in someone else's wrongdoing. I want at the end, even though there's a lot of logic here, to try to make it clear to you that being clear in one's thinking is not incompatible with being a caring person or a caring healthcare professional. There's sometimes that bias out there that if I'm going to make a logical argument like this, it necessarily means I don't really care about patients. I do care about my patients and I hope those of you who know me as a practitioner recognize that that's true. I also sort of want, in any of the talks I give about whether it's withdrawing a feeding tube or withholding a feeding tube for someone with Alzheimer's disease or this kind of question, to situate it in a larger context of the sort of meanings of human eating. It's not just nutrition and hydration, at least for us. You're eating now, but I would suggest that part of what you're doing is more than just eating. I guess the fat in the food you're getting from potbelly may help to increase the pleasure and satisfaction of what you're doing and there's also something interpersonal. Maybe, like me, you often have the danger during lunch of getting the crumbs on your keyboard, but it's good to be able to do that with other people and we try to do that with our families and communicate with each other through preparing meals and sharing them with each other and eating. And that's the real context for the human meaning of eating. Some assumptions to start with and so you know where I'm coming at from this. First, there are those people who think that that somehow medical interventions around feeding are not somehow medical interventions. I don't believe that. The insertion of feeding tubes, peripheral or central venous catheters, even interoclices, I think all of these things are medical interventions and not simply means facilitating normal human eating. So I'm on the side of those who say these are medical interventions. It's not just assisting normal human eating. And I also want to say from the outset that while I'm going to be talking about this very particular case, I fully support the withholding of medical hydration and nutrition and these kinds of invasive means from decisionally capable persons who refuse these interventions and that in most cases I think those are perfectly morally acceptable practices. But the issue I want to address is that it's been argued that this practice of voluntarily stopping eating and drinking, A, is somehow not suicide, that it's different from suicide, and that further physicians have a moral obligation to respect these decisions and cannot insert a feeding tube in such patients and I think most of us would have qualms about that, but then further to say that physicians also have a moral obligation to assist a patient who voluntarily stops eating and drinking and that such aid doesn't constitute physician assisted suicide. And the people who've put this kind of argument in the literature include prominently Tim Quill who's going to be here speaking in a few weeks, also philosophers like Bernard Gert have made similar arguments. Those are the questions I want to examine, whether that line of reasoning is actually sustainable if we're careful about our understanding. So the kind of case we're talking about just so it's clear for everybody, 75-year-old woman who's been having memory problems has recently been diagnosed with likely Alzheimer's dementia. She states she cannot bear the possibility of inexorable cognitive decline that she foresees for herself, and she states that she intends to stop eating and drinking as a means of bringing about her, hastening her death, and she asks to be admitted to the hospital and to be sedated as she does so. And this is the kind of case that's being presented as voluntarily stopping and eating and drinking and something that might be distinct from a suicide or for the physician's aid physician assisted suicide. So let's try to examine these kinds of claims. When do I hold that it's typically morally acceptable to withhold medical hydration and nutrition? Well, the typical cases that I think most of us are used to are when a patient is dying of an underlying lethal pathophysiologic condition whether that's a malignancy or end stages of a neurologic disease like ALS or Alzheimer's disease when a person's unable to swallow on their own bed bound under those sorts of circumstances where there's a progression expected for that disease. And secondly and importantly where there is a pathophysiological reason why the patient cannot eat or can eat only with grave difficulty or at high risk to their own well-being. So those kinds of cases might include obstruction obviously often include neuromuscular dysfunction either neurologically or at the muscular level or a pathophysiologic condition of anorexia as accompanies most chronic illnesses at the end of life persons who are dying of untreated tuberculosis or let's say it's multi-drug resistant tuberculosis those persons are going to have high circulating levels of catexin and are going to lose their appetite. People who have cancer at the end stages of that disease lose their appetites as a normal part of the pathophysiology of this ongoing progressive disease and those persons have a pathophysiologic reason why they are not eating. So persons dying of an underlying disease there's a reason why they cannot eat and either the intervention won't work and among those who would argue that in end stages of Alzheimer's disease the typical reasons we give for putting in feeding tubes really aren't addressed typically by those feeding tubes if it's to prevent somebody from having aspiration pneumonia then in fact it's rare that that would be the case because particularly if it's very end stages and the patient's lying flat on the bed the food you put in the tube in their stomach is going to go right back up the esophagus and down into their lungs anyway so it doesn't really help that or it isn't reasonably available I mean no one is saying we have an obligation to put feeding tubes into people in the developing world where these sorts of things aren't reasonably available or we've judged that the burdens of this sort of treatment outweigh the benefits for a patient again with a short time to live, with cancer or ALS lots of comorbid conditions associated with it and then importantly that our intention in not putting in a feeding tube or not hydrating such a patient in these kinds of cases is simply to not do the treatment that our intention is fulfilled when the patient is no longer receiving the treatment or it hasn't been initiated for the patient so there's no connection between the patient and the feeding tube then our intention is fulfilled under those circumstances I think we tip that's what we typically do and I think it's morally permissible under those kinds of circumstances to withhold or withdraw a feeding tube or central venous catheter or peripheral venous catheter or enteroclysis or whatever means one might want to suggest for providing hydration and nutrition for such patients in other words under those cases an instance of allowing the patient to die and what I mean by allowing to die acting with the specific intention in acting of withholding or withdrawing an intervention that would interfere with the progression of a pre-existing lethal pathophysiologic state and this is typically justified when the treatment is futile or excessively burdensome when the intention is that the treatment should cease not that the patient should cease and for those who worry about what their own intentions might be you have to think of the sort of counterfactual case were the patient to start breathing after you withdraw the ventilator would you say oh I failed let me quick get a pillow to smother the patient because the patient is still breathing or would you say that I have fulfilled my intention that the patient and the ventilator are no longer connected those are the kinds of conditions under which I think we can say that it is permissible to allow a patient to die now what's this voluntarily stopping eating and drinking well first of all it has to by definition involve a decisionally capable patient otherwise the V wouldn't be there it's got to be voluntary so it's got to be someone who has the capacity to say this is the case and either the patient doesn't have a lethal pathophysiologic condition or they're not at the very end stage of that lethal illness my way of sort of thinking about that would be other things being equal setters power boosts but for the decision not to eat that the patient could live for weeks to years and there is no pathophysiological reason why the patient cannot eat there is no obstruction there's no evidence of neuromuscular dysfunction and there's no pathologically explicable anorexia eating wouldn't be futile or dangerous but the patient has judged that the burdens of being alive outweigh the benefits of eating and continuing to be alive and the intention of the patient is to bring about his or her death by way of not eating that's what I think voluntarily stopping eating and drinking means at least I'm going to define it as under these circumstances now I want to suggest that it is not the withholding or withdrawing of a life sustaining treatment eating is not a medical treatment I don't think most of you who think what you're getting from potbelly right now is a medical treatment in fact it's probably medically contraindicated for you secondly, voluntarily stopping eating and drinking doesn't meet, if you just followed what I was saying the traditional criteria we use for assessing that it's a case of allowing to die because the cause of the death in this case would not be an underlying pathophysiologic condition for which eating is a medically indicated treatment and the intention of the act is not that the treatment should cease but that the patient should cease so it's not the typical case of voluntarily stopping eating and drinking being a case of typical allowing to die the way I have defined both of those terms now, what's suicide? well we can get a clue from other languages which are a bit more direct about it the German is selbstbord or self-killing that of course leads to the question of what is killing what does it mean to kill a human being and here's my definition of what that means it's acting with the specific intention and acting of creating a new lethal pathophysiologic state so that a human being should die by way of one's action now there are lots of ways we can do this we can stick a knife into someone's heart and create a new lethal pathophysiologic condition of the hemorrhage that's there and if we do so with the intention that they're going to die by having done that that would be an instance of killing likewise, if you put 150 million equivalents of potassium chloride into somebody's right ventricle through a catheter you're creating a new lethal pathophysiologic condition and I think the burden of proof would be on you as a physician to prove that your intention under such circumstances would be anything other than trying to make the patient dead and that's what I mean by killing and it's traditionally justified only in cases of self-defense or rescue where there's forced choice and certain death you might want if you're a just war theorist to expand the self-defense out to the defense of a nation to justify killing that way I have a harder time for those who try to make that same argument for execution I'm against capital punishment but some people try to make that kind of self-defense of the community argument to do it but all of those would only be the exceptions in terms of acceptable killing but in all of those cases it's creating a new lethal pathophysiologic state in the patient with a specific intention that the patient should die by way of that action so what is suicide? Suicide is doing that to yourself creating a new lethal pathophysiologic condition in yourself with a specific intention in acting that you should die by way of the creation of that new pathophysiologic state what counts? well it could be those horrible and sad cases in which people put a gun to their heads and they create a new lethal pathophysiologic state with a specific intention they should die by way of that action where people overdose on drugs with a specific intention that that overdose state should be toxic to them and they should die by that those are the typical cases of suicide by these definitions it seems to me pretty clear that voluntarily stopping eating and drinking fits the definition of suicide it is intentionally creating a new lethal pathophysiologic state that of starvation and dehydration with the specific intention in acting of making oneself dead by way of that act our normal physiology leads us to eat and maintain our state of nourishment and hydration and to voluntarily stop eating and drinking is to create a new lethal pathophysiologic state which wasn't there before and if one does so with the specific intention of making oneself dead by way of that act it seems to me that that fits the definition of suicide so what's assisted suicide? again, it's aiding another person in suicide aiding somebody else in their killing of themselves and when the person who does the aiding is a physician we call it physician assisted suicide in the jurisdictions in which this is legal the physician writes a prescription for a lethal dose of barbiturates and the patient then takes those if they carry it out with a specific intention in acting of creating a new lethal pathophysiologic state within themselves of an overdose of barbiturates with a specific intention that they should die by way of that action and if the physician writes the prescription the physician is actually then assisting the patient in that suicide what are the ways we can assist somebody in something like that? one way is by suggesting the action so those of you who are familiar with the Hippocratic Oath it says I will not give a deadly drug to a patient even if asked nor make a suggestion there too so the suggestion is actually 2,500 years ago sort of included in the ambit of the things that at least the Hippocratic Oath thought would be prescribed so suggesting it is a way of assisting giving instructions here's how you do it providing sanctuary or cover for somebody is a way of assisting them in an action facilitating or easing the action is a way of assisting a person in their action or failing to prevent when you've got a role specific duty to prevent it is another way of assisting someone in an action that you consider to be a wrong action so I think then again by these pretty simple straightforward definitions that voluntarily stopping eating and drinking is a form of physician assisted suicide if the physician for instance encourages or suggests it which again is becoming very common in the literature you know you're not in a state where I can give you a legal prescription but you could stop eating and drinking if you'd like that is a form of assistance in this action which fits the definition of suicide if you instruct the patient in how to do it if you provide cover for instance misdirecting others who might intervene or persuade the patient to stop it if you agree to ease possible accommodating symptoms by promising hospitalization or sedation you are assisting the patient in this action if you do not attempt to dissuade the patient or suggest alternatives in some ways at least within the jurisdictions in which physician assisted suicide is illegal then you are actually assisting the patient in that because you have a role specific duty not to assist this gets us of course into a complicated issue which is the ethics of complicity of being an accomplice in someone else's wrongdoing if one considers this to be wrong and again this is all a conditional argument so you can do that formally if you share the intention of the person so that you say yes I think you should do this I want you to do it I think it's best for you here's how to do it then you share the intention but even if you don't you can be someone who supplies the means whether they're social or material you can facilitate it you can fail to prevent and be implicated in the wrongdoing of another person it's another whole lecture to go into on the ethics of complicity but these are the kinds of ways in which that could be the case therefore and again this is all conditional I'm not arguing whether physician assisted suicide is right or wrong but if it is wrong then physician assisted voluntarily stopping eating and drinking is wrong I think it's simple deductive logic it's following standard definitions and ordinary language and it baffles me that there has been a literature that suggests anything to the contrary so what are the kinds of counter arguments that people might come up with against this or ways of trying to justify it that this sort of approach from me and I alluded to this at the beginning sort of lacks compassion here you're up here you're just this guy with a philosophy degree even though you're a doctor but I want to suggest to you I'm not Mr. Spock I don't have the pointy ears I can't even do the Vulcan mind melds I'm not guarded simply by logic I care about my patients who have these diagnoses and I want to care for them and accompany them through their suffering I'm not someone who is actually prone to torturing patients and I don't think that not participating involuntarily stopping eating and drinking amounts to torturing patients I do think that compassion is important in medicine but compassion needs some degree of reason to be true mercy and I think we ought to show mercy for our patients and not merely be guided only by our emotions emotions are important and we shouldn't be automatons but it shouldn't just be emotions everything I'll also tell you I'm not going to give this lecture to a patient who asks about voluntarily stopping eating and drinking any more than I'd give a lecture on viral epidemiology to a patient whom I was disclosing a diagnosis of HIV I'm making a logical philosophical argument I'm not prescribing for you how you should deal with this question in a clinical way where we have to be very careful and sensitive to the needs of our patients now the counter counter argument from compassion might be this how could you turn away a patient who had decided to do voluntary stopping eating and drinking and ask for your help with symptom management after all people do things that we think collectively are wrong and harm themselves like smoking cigarettes and we still give them bypass surgery is that complicity in their smoking or we give them nicotine patches when they're in the hospital so we're treating them in that sense they've been doing things that we think are wrong and we want to help them my reply to that would be first to point out that even though you might say people suggest that they commit suicide by smoking it's not as grave as the kind of suicide that I'm talking about but more importantly for example is not really analogous coronary artery disease is a consequence of this past action of smoking not a present concomitant of an ongoing wrongdoing that we are facilitating I don't think we have an obligation to help facilitate the smoking of our patients because they refuse to quit by giving them lidocaine spray to ease the sore throat that it causes them when they smoke I don't think any of us think we have that obligation as caregivers so the counter examples that people have tried to put up I think are actually misplaced the better form of the general case of a counter example of the general example here would be who somebody says I'd like to do X which we consider to be wrong X hurts me please ease the pain of my doing X whatever it might be I presume most of you will agree with me it's wrong to rob banks somebody says I'd like to rob the bank but the vault is electrified it would give me a shock if I touch the vault handle please turn off the electricity that's the way in which one is actually facilitating the wrongdoing in those circumstances another counter argument which has been mostly the one that Tim Quill puts forth that we have an obligation not to abandon our patients and I think that that's true and he would then say to not help the patient who is elected voluntarily stopping eating and drinking amounts to abandonment of the patient a reply to that is that I think we ought to offer to continue to treat that patient under an alternative plan of deeply compassionate care and accompaniment treating whatever symptoms they have to the best of our ability but but not going to the step of facilitating or participating in the patient's own plan I would point out that it is not necessary to see a physician in order to commit suicide alright so we don't have to be involved in this we don't even have to be involved in voluntarily stopping eating and drinking particularly what a patient chooses but a physician and a nurse and any other healthcare professional all of us are independent moral agents and we are not merely agents of the will of the patient so that if we're going to do something we have to do it together and if we have deep moral disagreement I don't think there is a general moral obligation for us to participate in what we think is morally wrong another counter argument that is quite common is simply to reject the distinction between killing and allowing to die what's the difference between stopping a ventilator stopping eating and drinking and giving somebody a lethal injection the patient is going to be dead at the end of the day and that's the all that really counts is the end of their suffering and there's no real meaningful distinction between killing and allowing to die well my argument to that is that means that the person is going to have to prove that I've made a logical error in setting up the distinction the way I have or they'd have to make an ethical argument that the distinction I've made marks no morally significant difference and that's a very complicated set of arguments that we might get into but at the end of the day if there's somebody who actually does reject the distinction between killing and allowing to die then there shouldn't be any moral objection to physician assisted suicide or euthanasia anyway so it shouldn't matter for such a person that voluntarily stopping eating and drinking is a form of suicide because they believe in physician or to believe in physician assisted suicide anyway so it shouldn't matter to that kind of a person is physician assistance in voluntarily stopping eating and drinking legal as has been reported expressed in the literature on multiple occasions and I think the guiding idea behind that is that physician assisted suicide is illegal in many jurisdictions but you can't legally force a patient to accept a feeding tube which is true and therefore we'll recommend voluntarily stopping eating and drinking as a legal form of physician assisted suicide and it should be okay because we can't force them we can't force feed them my reply is that I think that's morally disingenuous it's trading on ambiguities it's trying to get around the law and trying to say this is something different from physician assisted suicide just because there seems to be a cover for it and secondly that there really isn't any case law to support this there hasn't been a case in which anyone has attempted to prosecute somebody for helping a patient with voluntarily stopping eating and drinking it may not happen anyway but I don't think people can make the claim that it is legal when there is no statutory law that says it's legal and there's no case law to suggest that it wouldn't be possible to prosecute this as an instance of physician assisted suicide in jurisdictions in which it is illegal particularly if one does other things I'm saying that if a physician doesn't the feeding tube and would probably have to do other kinds of things like bring the patient into the hospital sedate them etc which is the sort of full guns that it may be that someone could prosecute such a person for physician assisted suicide there's no, it would be probably tough which is what even if you define it morally as physician assisted suicide it's going to be very hard to prosecute because it would be so ambiguous in those circumstances but I think somebody might possibly try to do so and if they did you can't necessarily say that you've got cover from it because that could be defined by a very zealous person as an instance of physician assisted suicide so there just is no case law I agree it would be difficult to prove which is part of why people want to do this but I don't think they can make the absolute claim they have that it is legal so how far do I think and this maybe gets to more the point of your question Dan, one ought to go when a patient refuses voluntarily stopping eating and drinking and what is morally opposed the first thing I think we always ought to do is to assess that patient for depression for altered decisional capacity whatever the cause might be secondly I think we would be obliged to share our opposition with them in a in a humane and compassionate way that I think we would have an obligation as persons who are opposed to assisted suicide to try to dissuade them from doing so that we ought to offer them alternatives for whatever symptoms or fears they might have we ought to recognize that a physician is ultimately not necessary for suicide particularly this form of suicide I don't think we should admit them to the hospital if we're opposed to by euthanasian assisted suicide I don't think we should prescribe sedation for them make house calls to see that everything is going okay I don't think, this is where Dan comes up that we should force feed such a person I would not do that unless there was a reason to believe that the patient lacked capacity like they were severely depressed I thought we could treat the depression and then get them back to a state in which they would want to be able to eat and I think I would hold physicians disciplinary responsible for assisting in jurisdictions where physician assisted suicide was illegal and that would include leaving open the possibilities or the possibility of discipline within a medical organization if one really wants to go that far we can debate that but I would go as far as that yes well it would be only we can get to these questions in a minute I think it would only be under the case in which they lacked decisional capacity so you could do that in these other possible related cases that might get to it so the kind of related cases that I wanted to bring up are an incomplete suicide attempt so the suicide is attempted let's say by somebody with Lyon gestion they survive but these esophagus is severely damaged the patient lacks capacity due to their underlying depression so they could be involuntarily admitted to the hospital and then in this case you'd actually probably to feed them have to do g-tube unless you had very good people who could get through the caustic injury without damaging the esophagus and I think a few gastroenterologists in the room wouldn't do that so I think you'd probably have to be surgical or if you thought it was short-term enough you could do maybe parenteral feeding for such a person another related case and interested in the way psychiatrists so think about this anorectics I don't think that most psychiatrists put feeding tubes into patients with anorexia for willy-nilly but while the patient certainly while the patient has any capacity for reason they would try to persuade that patient and treat them treat comorbidities such as depression but I think if lack of eating leads to a lack of capacity that's the point at which we would then involuntarily commit that patient and feed them to restore capacity and continue psychotherapy another related case which I think is even more complicated is that of hunger strikes because there we have to presume that the person who's doing it is decisionally capable but it's complicated because it's a form actually of political speech to be engaging in a hunger strike and it's also complicated by the fact that the real care of the state we're reluctant to force feed I'd be reluctant to force feed prisoners under these cases but I'm always perplexed by that if you ever saw that movie Some Mother's Son about the IRA hunger strikers and Helen Mirren's character who won her son but loses capacity says stop the madness and then all the other mothers come out and they actually force feed prisoners and there's some reasonability to that kind of kind of a reaction so I don't know where I come out on that but I think it's not sufficiently analogous to the voluntarily stopping eating and drinking that we're talking about so my conclusions the basic ones we can discuss a little at the edges are that voluntarily stopping eating and drinking is not the same as withholding or withdrawing life sustaining treatments eating is part of our normal physiology and that voluntarily stopping eating and drinking is then a form of suicide creating a new lethal pathophysiologic condition within oneself with a specific intention and acting of making oneself dead by way of that action a physician who assists with voluntarily stopping eating and drinking is therefore doing physician assisted suicide definitions of those and if physician assisted suicide is wrong then physician assisted voluntarily stopping eating and drinking would be wrong as well again I have not established and we can argue at some other point that physician assisted suicide is wrong this has all been a conditional argument if you want my arguments against that you can tune in on Thursday, November 13th on Intelligence Squared which gets I think live computer airplay and then is reproduced on NPR stations but Peter Singer and Andrew Solomon will be debating me and Baroness Elora Finlay who is a palliative care doctor and member of the House of Lords in the UK and will be debating the question of physician assisted suicide but I'd like to have the questions at least before we get into physician assisted suicide be solely on the question of whether physician assisted voluntary stopping eating and drinking is physician assisted suicide or not rather than whether physician assisted suicide is right or wrong but we can get into that later so questions, concerns, objections I'm happy to answer and entertain any and all, yes thank you Dr. Solomacy we have time for questions this is the way we're supposed to do it here I guess you get the I take the microphone and you point out who gets the questions very clearly reasoned where I get caught up is the active passive distinction and I see shooting yourself actively as more suicidal than passively not continuing to eat and drink and also I see sedating somebody as more active than not preventing them so the suicide and the assistance part I think I see a distinction there the active this is more generally on the distinction killing and allowing to die the active passive distinction can't really mark the moral distinction because there are certainly cases in which one could have a moral obligation role responsibility to help somebody and not do so so if I am a lifeguard and somebody is drowning and I know that if they drown they're going to give a million, if they're dead their will says they're going to give a million dollars to the McLean center for clinical medical ethics and I just stand there with my hands behind my back and I'm sitting there my passivity is in fact I think most people would judge and I think you would agree morally wrong so the active passive distinction does not mark itself the moral distinction killing will always be active but the way I look at the logic of it and I guess I have a slide on this I think it might come up is yes, all killing would be morally wrong except in cases of self defense and rescue but some allowing to die is morally permissible and some is not and some of the morally impermissible allowing to die is when one has a nefarious motive and acts for these other sorts of reasons so you can't make it just on the active passive distinction and that would be a little more than that I have a mic to continue on that on that vein it seems to me that the difference between shooting yourself and voluntarily stopping ingestion is that you can hedge your bet until the point where you become unconscious and that the reason to me that sedating that person is wrong is that you've pushed him along that continuum you've taken away the ongoing decisional capacity actively and I've been asked for that so that's my take on that I'm always puzzled by the issue of depression it seems to me that just to take a public example of David Foster Wallace someone who has been treated repeatedly repeatedly and has come to think of the depression as an illness that will never admit that whose treatment is futile and onerous and causes him more suffering that it's a little bit facile to say that suffering is something I should always intervene in and that that suffering alone takes away decisional capacity it seems to me that it might be a very good reason to commit suicide in that sort of situation I'll agree that there are plenty of different ways to bring about one's death and that some of which are slower and would admit of the possibility of reversal I think the same kind of thing happens in a lot of drug overdoses and there's certainly the psychiatrist in the room for many people it's actually more a gesture than it is actually a suicidal intent at the end and people can be rescued from those sorts of things so the ways in which it doesn't change the moral structure if your real intention is to make yourself dead and that continues to be the case all the way through until you are dead then the moral structure is the same regardless of whether the pathophysiologic state occurs quickly or not but I'll agree with you that certainly there are chances to change your mind if you're doing something slower you know if you're giving yourself a little bit of arsenic every day and you could stop at some point and I could agree with that so it's a little less dangerous quick but it doesn't in the end change the intentional structure with regard to suicide and decisional capacity and depression not all persons who are depressed lose decisional capacity so the person who is depressed and suicidal generally is so because they have a distortion in their judgment they think that the world is awful, would be better off without them etc but they have at least enough capacity to know what would happen if they put the gun to their heads but it usually hangs a lot on their judgment in those circumstances so you're correct to say that not everybody who's depressed has thereby lost decisional capacity there are lots of people who are depressed who still have decisional capacity I have a little difficulty with the notion of the phrase allowing patients to die it's often used to I think it sort of gives the physician this illusion of power which is not existing for example should we do CPR or allow the patient to die should we allow the patient to die now or in 20 minutes from now and very often that's what allowing the patient to die is and I think that needs to be separated from the real thing of a patient who we're allowing to die because they're going to do something that's really going to end in their death so there's really different concepts I think you need to parse out that allowing to die thing because it's so overused and it really makes it really empowers physicians to this degree that I think is not warranted that's a good point within allowing to die there are some of the justifications which are futility which in some ways you're pointing out is oxymoronic they're dying anyway it's more of a recognition that they are dying but there are other cases in which life could be prolonged fairly substantially which we might allow someone to die let's say there's somebody who's paraplegic and ventilator dependent right and we honor the choice of that person to discontinue the quadriplegic sorry and we allow that person to discontinue the ventilator under those circumstances I mean that is a little bit more of allowing to die in a sort of a stricter sense that you want to use it both of which I think are distinct from voluntarily stopping eating and drinking in which there is no underlying pathophysiologic condition which would in but for the stopping and eating and drinking result in the patient's death within a very short period of time who's got a mic left so you're supposed to be helping Christian and so Thanks Dan, great talk so as usual it seems to me that this whole lattice work hinges on intention and I would argue that intention isn't always clear or unambiguous and it seems to me that there could be times and places with the case that you gave of 75 year old I mean there are two different kinds of variables with that intentionality one is over the course of her condition that individual person by even your own argument she will reach a point where you believe it is an appropriate kind of thing not to continue to eat I mean that is a predicted outcome for her and she knows that at a time we have enough knowledge and predictive value so it seems to me that actually changes her intentionality she could look around and say well I'm going to be using a lot of resources and that's futile in my ultimate end or she say I may have lived a happy life but out of my fate has destined for me to go and so her intentionality may not be to take her own life but to accept this condition that is progressing and to hand off her resources to other people so her intentionality may not be to die but to accept this condition and to not take resources from the young and so that would really change her you have to be careful to distinguish intention from motive right so motives are motives are distinct from intentions right they can be the sort of furthest intention one has but they are often posterior motives like revenge is a motive of something that happened in the past and we also may have wider motives for doing something and generosity towards others would be a good motive what I'm talking about is the specific intention in acting so what fulfills the intention of the patient who says I want to die now right within the next two weeks I'm going to stop eating and drinking so that as a further intention other people might use the resources so that initial intention becomes has to be intended because it is the means for which she is achieving the further intention which is perhaps her motive so you've got to be very careful with your motive from intention but that requires you to say that her taking the food is morally obligatory because otherwise she could say no my intention is to not consume resources and I know that a secondary consequence of that well then you've got to sort of ask people you know reason so again this is logic is it logically possible to say that my intention is not myself it is only to remove myself as a user of resources that would be used by other people by making myself dead but I don't actually intend myself to be dead that seems to be actually illogical because one is the means by which the other is being achieved and you really can't sustain that nor can you sort of which often happens and people like Tim Quill try to do this change the morality of something by you know or the intention by act re-description so take two examples this is common in the philosophical literature Oedipus marries Jocasta and Oedipus marries his mother if Oedipus knows that Jocasta is his mother then he can't say I intend to marry this woman named Jocasta but I don't undertake the intention to marry my mother even though I know that those are two different descriptions of the same event so you can't be disingenuous that way if you're going to be serious about these things no because they would be the same effects there's no double effect and in this case here the means that one of the conditions in double effect is that the end cannot be achieved by the means so if the means of redistributing resources by making oneself dead that means to towards the other end so it violates the third condition of the rule of double effect what concern me is that sometime we as Oedipus pretend and try not to know whether it was our mother or it was not our mother and we do things which is not rational say we have someone not to be eating of me know that that person wants to commit suicide and so we say as if we should help him based on compassion or not but the basic question is whether or not we believe in committing suicide is a person's right or it is not and what puzzles me you may find very rational people like Kent who is so rational and he believes that the autonomy is the sole purpose of moral or is the origin of moral and on the other hand he says that committing suicide is wrong or you for example give such a good lecture but at the end I didn't find out whether you are in favor of suicide or not and so I just wondered if you are courageous enough to say yes or no or would you let me keep thinking I'm opposed and what I did say is you'll find out more about why I'm opposed if you want to tune in on November 13th but I'm opposed but the argument that I made was conditional so just sort of calling a spade a spade even if you are in favor Dan thanks for a great clear really marvelously lucid lecture it reminds me as a good lecture does that philosophy is hard and that it's really hard not to have a view that's over or under inclusive and I wonder whether even from your own perspective this one might be over inclusive and I wonder whether some of your distinctions are attempts that need more sort of development to try to keep that from happening so as Peter says one of the fulcrums here is the concept of intention and intention is understood to refer to the description under which one performs an action so and that doesn't mean that actions that you know will lead to your death or therefore suicide when the soldier throws himself on the grenade to save his comrades his intention and actions to save his comrades not to kill himself so even though he knows he will die and so similarly some of these other kinds of examples might be handled by simply pointing out that suicide is not the intention in action or it could also be the case that because it has downstream effects it is suicide but when you focus on intention this way and then on the other notion of a sort of a wide notion of assisting I'm concerned with two very general with one general thing and one more specific kind of case the general one has to do with the thought that it looks to me as if all sorts of decisions to stop care even under conditions in which someone will die imminently count as suicide because in many of those cases the accurate intention description of the intention of the patient is to die the reasons may have to do with stopping pain and so forth but the correct description of what they're trying to bring about is their own death and so I'm not at all clear why a lot of what you have there are different actions that involve imminent from actions that involve longer term demises are really relevant but in the same way it seems to me then that also the concept of aiding that you're using is a broad one and you're doing that because you think there are a lot of things physicians do in the way of counseling in the way of winking the eye that you think for patients who are attempting to stop food and nutrition that those two counts is aiding it looks to me that with that notion of intention and that notion of aiding that if I wish to have my ventilator removed and let's to make it easy imagine that I could live 20 more years but the condition in which I'm in is intolerable to me that looks like it counts as suicide and it looks as if removing the ventilator counts as aiding I understand that you could describe the physician's intention in that case not as trying to bring about the patient's death but nonetheless it seems to me that can also there are ways in which I think it might be accurate to say that physicians who assist patients who are trying to stop food and nutrition are not best seen as intending to bring about the patient's death but intending something else which might seem perfectly acceptable so it looked as if the distinction you wanted to make to cover this case is that in some way having a breathing tube doesn't so it moves you out of the realm of engaging in a standard natural activity whereas eating and drinking are in some way natural activities and that's where I'm wondering whether that's not a cogent move breathing is a pretty natural activity we shouldn't be misled by the fact that breathing tubes are large things as you know the technology increases they could be tiny so that the patient could look as if there's nothing going on and so it does look to me as if your argument entails that removing a breathing tube is physician assisted suicide and since I think you believe that removing a breathing tube under appropriate conditions is morally permissible it looks as if there's a tension going on there well lots of questions buried within your comments and you know probably the next book is going to be an attempt to sort of work out most of those but I have a fair set of answers to some of it first there's a distinction between intention in acting and further intentions right so what I'm limiting the moral responsibility to here is the intention in acting and not to the further intentions that of course requires also a moral distinction between intention and foresight which also needs to be justified I think a lot of this from Michael Bratman intentions plans and rational action in terms of the action theory that's going on here John Searle as well and so but I'm giving it more of a moral valence they were simply talking about in terms of philosophy of mind so what I'm limiting it to is what are the conditions of fulfillment of one's intention in acting and that is fulfilled as in the case of Karen Ann Quinlan where the patient and the ventilator were disconnected from each other right you could have the belief that the patient was going to die that was your foresight you could have the desire that the patient would die but the court's order was fulfilled and the intention in acting was fulfilled when the patient and the ventilator were discontinued and that's where I'm hanging the most significant moral weight it also requires as you're suggesting though this intention foresight distinction and that requires separate philosophical defense as well in terms of it well it's yes so that's the other part of the answer and we'll probably get onto others it's not just intention so the complex definition of killing requires allowing to die requires knowing about the state of the patient pathophysiologic condition where there's a treatment which is stopping the progress of that so it's not just intention in which this distinction hangs but several variables which are built into the definition you're right if it's only intention that your arguments would have some cogency but it's not just intention that matters more than intention matters I'm sure you're going to be able to elucidate this better than I'm going to be in presenting it when we look at the comment about active and passive that was earlier and then what physicians do and your inquiry let's stay on the issue of physician assisted suicide when I juxtaposition atul gawande's conference last week and the information either in his book I read it or he delivered it he said that we end up taking patients to surgery many times when their benefit from that surgery we now have collected data is inverse to what we intend to do meaning the surgery that they get in the last 24 hours usually accelerates their death and in the last six months of life many of the things we do where we expend resources are futile so how would you answer a question on intention and looking at the cold scalpel as arguably okay but the warm soft removal not okay because I'm grappling with all of the actions that a physician takes not the singular restriction or voluntary assistance of removing, eating and drinking part of your question is do we in fact undertake a lot of interventions which are either futile or more burdensome than beneficial at the end of life and the answer is absolutely yes and am I in favor of desisting from those patients or at least at the very least letting patients know more clearly that the benefits are that limited and in some cases not even offering them because they are so futile then the answer for me is resounding yes so I'm not somebody who's saying we have to and that's not the point of this is we have to treat patients I'm totally in favor of withholding and withdrawing life sustaining treatments that are futile or more burdensome than beneficial or more injury which may be undertaken with the intention of making the patients life better then we get into another whole part which is the book after the book after which is on self-deception but that's another issue altogether so one could argue that we know that as patients are aging there is a decrement in their ability to eat and drink as they go along one of the final things you see whether it's a cancer patient patient with Alzheimer's the intake decreases so we could say that in some way we are doing sedation or accommodating what is a natural process how would you answer that in a philosophical construct it could be the moral equivalent of giving Tylenol for pain again if a patient has reached the end stages of a disease as is often the case in patients with end stages of malignancies end stages of tuberculosis untreated HIV what's one of the things that happens to people is they lose their appetites as part of the natural process of dying generally that's not painful and I suspect our palliative care doctor here would tell us that there's not much of an indication in those cases for giving morphine for that but if the patient did have some sort of discomfort which required treatment then I'd be more than happy under those cases to give them that treatment but they have a pathophysiological reason to explain the fact that they are not eating under those circumstances there might be other causes of pain which are due to comorbidities as well maybe we should go on to another question or if we've got enough time enough time one final question one more from Robert you get two, yeah so I'm thinking about other I'm sort of resisting your point of view and I'm trying to identify what's making me resistant part of it is that I think by nature we're all dying and eating and drinking keeps us alive which is kind of artificial so in a way letting ourselves die is kind of letting nature take its course that's kind of the default fate of all of us so that's one piece another piece is that I'm interested in your exceptions for example self defense is an exception could you frame voluntarily stopping eating and drinking as kind of a self defense this inextrable cognitive decline for example in your case so the first thing on Bach the unnaturalness of eating I guess it depends on what you're eating and maybe justifies the natural food movement but I just recently have a cat and I wish I could get this cat to stop the natural process of eating as much as it seems to want to which is part of I think our natural tendencies as organisms we exist by eating actually Leon Cass is a wonderful book just on eating how the boundary between organism and environment depends on some intake continually of things from the external environment which is in some ways the most primitive meaning of eating and it's part of the law like generalizations and typical history and features which characterize any living biological being as the kind of thing that it is so I think that's how I would say that it's natural the argument about self defense depends really on a dualism that I won't accept which is that I am something different from myself and therefore or from my suffering that's going on inside me and that I can defend myself from myself in this sort of complex way and I just don't buy that kind of disembodied person defending itself against the bodied person who's suffering I just don't buy that philosophically and I'm thinking about hunger strikes like if political speech is maybe okay why can't you see the voluntary stopping as not just political speech but a self decision suicide is always and this I learned from Ned Kasem actually suicide is always an act of communication it is always an act of communication he says that his question before someone asked about and the idea that it's a purely self regarding action is nonsense his question for patients he said who were contemplating suicide was always in whose closet to leave your skeleton the person who's committing suicide is always saying something I agree with that the question is do we want to allow them to have that as the final thing that they say about themselves or about others and I would rather say or they're just sort of testing the waters to say does anybody care enough to try to stop me I care enough to try to stop people final notes so thank you