The issue in bioethics can usually be reduced to the debate over life and death – is it ethical to kill someone or is it ethical to preserve human life even against the person’s will? Is the sanctity of human life more or less valuable/important than the quality of human life? In this log entry, I will try to tackle this very vague question through the lens of the principle of ‘Do Not Resuscitate’ (DNR).
DNR is a policy in hospitals wherein when a patient flatlines (i.e. their heart stops beating), the physicians are legally obliged to not commence CPR and try to stimulate the heart into beating again. Before a patient goes into surgery where there are considerable risks – for example, they could be rendered permanently vegetative or paraplegic – they are given the choice to sign a DNR. The principle and the legality of DNR are very contentious and many nations around the world have different opinions on it; for example, DNR is legal in the USA, but it is illegal and heavily rebuked in India. In this log entry, I will be analysing the moral implications of DNR in order to ascertain whether personal autonomy should be considered more morally important than the principle of the sanctity of human life. Through this analysis and evaluation, I will then be able to make a justified decision over whether the sanctity of life should be considered to have a greater moral weight than the quality of life.
Firstly, this debate directly comes under the issue of personal autonomy. The patient is signing their rights to life away before surgery – they are blatantly promulgating that, if their heart is to stop beating, they do not want to live. Usually, this is because when one’s heart stops beating, the oxygen supply to their brain gets cut off and can sometimes cause a vegetative state (a.k.a ‘brain-dead state’). Philosophers have largely contesting views on this matter: those who support the sanctity of human life say that life has an intrinsic value (be it because it was given to us by God or because we were created ‘specially’ to live), so we have a moral duty to preserve and fight for life. However, the counter view on this argument is the proponents of the quality of life: these thinkers understand that human life does have intrinsic value, but also states that there are extrinsic factors that should be considered. They also heavily emphasise that humans should have the freedom to dispose of their own lives as they wish (this is the basic premise for ‘personal autonomy’ in the issue of bioethics). The entire tenet of the quality of life argument is that it negates the absoluteness of life (i.e. it states that life does have value but people should also have the right to choose what to do with their own life) and argues that people should have the right to die when they see fit. More often than not, people are not willing to dispose of their own lives without valid reasoning – they often sign DNRs when they recognise that they may be rendered entirely dependent on a ventilator for the rest of their lives if they flatline in the Operating Room (OR). People often choose to die when the negative implications of being alive – the extrinsic qualities of human life – outweigh the intrinsic value that human life has.
However, there is a large divide here: how can one ever, quantifiably, state that the extrinsic factors of life outweigh the intrinsic value? Unlike Bentham’s Hedonic Calculation which tries to numerically measure and assess happiness, ethical questions like these cannot be mathematically solved. This is where the principle of patient autonomy comes in. If one is in a rational state of mind, they should be able to make a decision which can be upheld in court. For example, one would never call someone who was intoxicated at the time of a murder to testify in court as they were not functioning rationally and may not recall the events of the day correctly. Following this notion, should a rational person not be given the right to choose the future of their life? Culprits of mass crimes are given plea deals in the court of law where they are sent away for a life sentence in prison – these culprits are given the right to choose the future of their life. They will be held in prison until the day that they die; this plea deal is essentially a prolonged decision to die. If the court of law and people generally believe that it is moral for someone to sign a plea deal stating that they will be sentenced to life in jail, is it not then a rational transition to believe that people should be given the right to be sentenced to life in the afterlife (i.e. the right to die)?. Personal and patient autonomy is largely upheld and given very strong moral weightage so why should they not apply to direct death (in contrast with the ‘prolonged death’ that I previously mentioned in this paragraph)?
Immanuel Kant’s theory on the sanctity of human life, surprisingly, would concur with my judgement and belief that the DNR policy is morally justified. His theory on the Categorical Imperative states that one should never directly harm another person – one should always act according to a fundamental maxim of the universe. The act of not resuscitating someone when they have died is an ‘indirect’ form of harm: this is a form of harming someone inadvertently as they are already dead. You are not making a conscious decision to kill them or actively harm them, but rather you are making a conscious decision to not do anything and, thereby, leave them dead. This does not violate Kant’s theory of morality as it does not directly harm someone. This thought experiment and use of the term ‘indirect harm’ is very analogous to the Trolley Problem. The Trolley Problem – as proposed by Judith Jarvis Thomson – is an ethical dilemma where people have to choose who gets hit by the trolley. People are usually divided when it comes to whether the trolley should swerve off the tracks and hit one person or whether it should continue down its original path and kill five. People who support letting the trolley run its original course of action usually state that they do not want to get involved because committing an action holds moral weight itself while standing idly by does not.
The reason that this debate is a lot easier to understand and actually talk about is because the principle of DNR only applies to when the patient has already died. Although the patient could be resuscitated, they have already lost the intrinsic value that they possessed – Upanishadic Hindus would state that their Atman would have already been returned to the Brahman. Proponents of Natural Law state that the most heinous crime is to go against what is natural in human life (i.e. killing is wrong because it is going against the principle of life itself), but, at the end of the day, isn’t death just another natural incident? Isn’t it just the last stage of life – a natural ending to human life? Because of this, I believe that the principle of DNR is morally justifiable only if the patient is rational.
One could emulate my evaluation to state that the quality of human life is more important than the sanctity of human life, but I would only believe that my argument holds true when the sanctity of human life has been subverted (i.e. when one has already died). Other interesting case studies and moral dilemmas which could be used to determine whether the quality of life should have a higher moral weight than the sanctity of life could be the issue of abortion which is the direct opposite of DNR where an intrinsic value of life is ‘blossoming’ – the life is growing and, therefore, so is the value of the life – but one wants to remove that intrinsic value because of extrinsic factors.
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