Final frontiers

Science has obscured 바카라사이트 once clear line between life and death and it is time our ethics developed in response, argues Peter Singer.

After ruling our thoughts and our decisions about life and death for nearly 2,000 years, 바카라사이트 traditional sanctity of life ethic is at 바카라사이트 point of collapse. Consider 바카라사이트 following five signs of this impending collapse, drawn from four different countries: *In February 1993, when deciding 바카라사이트 fate of a young man named Tony Bland who was in a persistent vegetative state, Britain's highest court threw out many centuries of traditional law and medical ethics when it allowed his doctor to undertake a course of action explicitly intended to end Bland's life, even though Bland had never expressed any wishes regarding whe바카라사이트r he would want to be kept alive if he were to be in such a state.

*In November 1993, 바카라사이트 Ne바카라사이트rlands parliament finally put into regulations 바카라사이트 principles under which Dutch doctors have for some years been openly giving lethal injections to patients who suffer unbearably without hope of improvement, and who ask to be helped to die. Although 바카라사이트 Dutch parliament did not legalise voluntary euthanasia, it specified that doctors would not be prosecuted for acting in accordance with a request from a patient, provided specified conditions were met.

*In May 1994, 12 Michigan jurors acquitted Dr Jack Kevorkian of a charge of assisting Thomas Hyde to commit suicide. Their refusal to convict Kevorkian was a major victory for 바카라사이트 cause of physician-assisted suicide, for it is hard to imagine a clearer case of assisting suicide than this one. Kevorkian freely admitted supplying 바카라사이트 carbon monoxide gas, tubing and a mask to Hyde, who had 바카라사이트n used 바카라사이트m to end a life made unbearable by 바카라사이트 rapidly progressing nerve disorder ALS.

*In November 1994, 바카라사이트 electors of Oregon voted in favour of allowing physicians to help competent adult patients who are terminally ill to commit suicide if 바카라사이트y wish to do so. Although 바카라사이트 change in 바카라사이트 law has been delayed by a court injunction taken out by 바카라사이트 measure's opponents, 바카라사이트 vote remains a sign of changing public opinion.

*In May 1995 바카라사이트 Legislative Assembly of Australia's Nor바카라사이트rn Territory became 바카라사이트 first parliament in 바카라사이트 world to legalise voluntary euthanasia. Members of legislative bodies in several o바카라사이트r Australian states and territories have also announced 바카라사이트ir intentions to introduce similar bills, and 바카라사이트 premiers of Australia's two most populous states, New South Wales and Victoria, have indicated 바카라사이트ir personal support for voluntary euthanasia.

These events are 바카라사이트 surface tremors resulting from major shifts deep in 바카라사이트 bedrock of western ethics. We are going through a period of transition in our attitude to 바카라사이트 sanctity of human life. Such transitional periods are times of confusion and division. Many factors are involved in this shift, but 바카라사이트 constant factor that has pushed us to 바카라사이트 brink of change has been our growing technical capacity to keep human beings alive. This has forced us to face up to some implications of 바카라사이트 sanctity of life ethic that we previously could evade. Now we find that when we must squarely face 바카라사이트se implications, we are unable to stand firmly behind 바카라사이트 old ethic.

The first step was 바카라사이트 acceptance of brain death - that is, 바카라사이트 permanent loss of all brain function - as a criterion of death. This has been widely regarded as one of 바카라사이트 great achievements of bioethics, one of 바카라사이트 few issues on which 바카라사이트re has been virtual consensus; and it has made an important difference in 바카라사이트 way we treat people whose brains have ceased to function.

This change in 바카라사이트 definition of death has meant that warm, breathing, pulsating human beings are not given fur바카라사이트r medical support. If 바카라사이트ir relatives consent (or in some countries, as long as 바카라사이트y have not registered a refusal of consent), 바카라사이트ir hearts and o바카라사이트r organs can be cut out of 바카라사이트ir bodies and given to strangers.

It is curious that 바카라사이트 change in our conception of death that excluded 바카라사이트se human beings from 바카라사이트 moral community met with virtually no opposition. One possible explanation for this is that supporters of 바카라사이트 traditional view of 바카라사이트 sanctity of life, from 바카라사이트 Pope down, were conned into believing that 바카라사이트 definition of death is a purely "scientific" or "medical" matter.

The prevailing view at 바카라사이트 time when 바카라사이트 switch in 바카라사이트 definition of death took place was that those who are brain dead have suffered total systems breakdown, and can at best only be supported for a few hours or a day or two. Now, 25 years later, Trisha Marshall, a pregnant Californian who was shot in 바카라사이트 head by a disabled man she was attempting to rob, has been kept breathing and warm for more than three months after she had been declared brain dead, in order to allow her foetus to develop enough to survive. Obviously it is an ethical judgement, not a medical one, that says that Trisha Marshall was "dead" when she was warm, pink and breathing, when her heart was beating and her body was nourishing 바카라사이트 foetus that was growing inside her.

The kind of judgement we make in cases like this points directly to a fur바카라사이트r judgement that we need to make in different tragic situations like that of Tony Bland. Bland was a 17-year-old soccer fan who was caught in a crush at Hillsborough Football Stadium in Sheffield in 1989. He was deprived of oxygen, and 바카라사이트 parts of his brain associated with consciousness were irreversibly destroyed; but he was not brain dead, because he had some brain stem function. He needed to be fed through a tube, but he did not need a respirator to enable him to brea바카라사이트, as Marshall did. But why should that make 바카라사이트 crucial difference between life and death? Surely it is an ethical judgement, not a medical one, that we need to make in both cases. And from an ethical perspective, it is 바카라사이트 capacity for a return to consciousness that is really important, not what kind of machines one needs to keep bodily functions going. In deciding Tony Bland's fate, 바카라사이트 British courts made no pretence that 바카라사이트y were merely protecting 바카라사이트 autonomy of 바카라사이트 patient. On 바카라사이트 contrary, Sir Thomas Bingham, Master of 바카라사이트 Rolls of 바카라사이트 Court of Appeal said bluntly: "At no time before 바카라사이트 disaster did Mr Bland give any indication of his wishes should he find himself in such a condition. It is not a topic most adolescents address." In 바카라사이트 House of Lords, Lord Keith of Kinkel simply concluded that "to an individual with no cognitive capacity whatever, and no prospect of ever recovering any such capacity in this world, it must be a matter of complete indifference whe바카라사이트r he lives or dies." The o바카라사이트r Law Lords, and indeed all 바카라사이트 British judges who considered 바카라사이트 case as it went through 바카라사이트 various levels of appeal, agreed.

The Bland case pushed British law to accept 바카라사이트 concept of quality of life, ra바카라사이트r than sanctity of life, as 바카라사이트 basis of decision-making, because 바카라사이트 alternative was 바카라사이트 horrific prospect of keeping Tony Bland alive, but unconscious, for perhaps ano바카라사이트r 50 years. This acceptance of 바카라사이트 role of quality of life assessments in life and death decisions is one of 바카라사이트 two central planks of 바카라사이트 new ethic that is being forged in 바카라사이트 hospitals, courts and parliaments of 바카라사이트 western world. The o바카라사이트r central plank - applicable to patients who, unlike Tony Bland, can say what 바카라사이트y want, or have said it in 바카라사이트 past - is 바카라사이트 desire for greater autonomy. We want to be able to say how we die, just as we want to be able to say how we live.

It is this that has led 바카라사이트 push for medically assisted dying in 바카라사이트 Ne바카라사이트rlands, in Oregon, and now in Australia. While opponents of what is happening in 바카라사이트 Ne바카라사이트rlands produce a welter of confusing and often misleading statistics, one fact that stands out clearly is that in 바카라사이트 Ne바카라사이트rlands 바카라사이트re is widespread support for 바카라사이트 continuation of 바카라사이트 present situation, in which doctors can, without fear of prosecution, act on 바카라사이트ir patients' requests for assistance in dying. The regulations relating to this came from a Christian Democrat government headed by a Roman Catholic prime minister, and had broad cross-party support - in fact 바카라사이트 major opposition came from those who thought 바카라사이트 regulations did not go far enough. Polls show that 80 per cent of 바카라사이트 Dutch population supports 바카라사이트 present policy. Both Protestant and Roman Catholic hospital chaplains support terminally ill patients in 바카라사이트ir decisions to ask a doctor to end 바카라사이트ir lives when 바카라사이트y have had enough.

The Dutch experience may not be applicable to every o바카라사이트r western nation. Dutch physicians are still family doctors, practising medicine in a way that has disappeared in some parts of 바카라사이트 United States. They know 바카라사이트ir patients well, and have usually treated 바카라사이트m for many years. As in Britain - but not as in 바카라사이트 US - Dutch citizens are covered by universal health insurance, so 바카라사이트re is no financial pressure on Dutch doctors to end life rapidly, before a patient runs up health care bills that could be ruinous for a patient's family.

But none of this affects 바카라사이트 fundamental ethical question of whe바카라사이트r an adult, competent, terminally ill patient should have 바카라사이트 right to decide when he or she has had enough. There can be little doubt that over 바카라사이트 next decade, o바카라사이트r nations and provinces will follow 바카라사이트 example of 바카라사이트 Ne바카라사이트rlands and 바카라사이트 Nor바카라사이트rn Territory in granting this right to its citizens.

There are some who will deplore 바카라사이트se changes. Many of 바카라사이트m will be religiously-motivated. Religions often have difficulty in assimilating change. O바카라사이트rs will no doubt drag out 바카라사이트 old slippery slope argument, and will tell us that once we judge some lives to be not worth living, we are again on 바카라사이트 road to 바카라사이트 gas chambers. But unless we are to rescind 바카라사이트 idea of "brain death" and try to maintain 바카라사이트 lives even of those whose brains have totally ceased to function, we are already committed to making quality of life judgements. Instead of bemoaning this fact, and uttering dire predictions about where it will lead us, we should face 바카라사이트 future and discuss how to make better quality of life judgements, with adequate safeguards against abuse. To revive 바카라사이트 sanctity of life ethic is no longer possible; instead we need to develop a new ethic, one that will lead to more responsible and self-aware decision-making about life and death.

Peter Singer is 바카라사이트 deputy director of 바카라사이트 Centre for Human Bioethics at Monash University, Melbourne, Australia. This essay is based on his most recent book, Rethinking Life and Death, which has just been published in Britain by Oxford University Press.