Forced abandonment and euthanasia: a question from Katrina

Social Research, Spring, 2007 by Kenneth Kipnis

Along with abandonment, euthanasia is also commonly prohibited by authoritative professional standards.

Facing the Dilemma

To fix ideas, let us restrict our focus to cases that arise only under the following three conditions.

1. The care setting has become hazardous to the point where clinicians are no longer under a duty to remain.

2. The patients who are being attended in the care setting are not expected to survive with the treatments that are available there. Nor is it expected that supplemental clinical resources will become available in time to improve their prognoses.

3. It is not possible to evacuate these patients.

There are at least three considerations that support excusing euthanasia under these specific circumstances.

1. Clinicians who abandon the care setting early, leaving others to take up the common burden, are able to sidestep the problem. Only the clinicians who stay on to the last will have to choose which of the two medical norms they will betray. To charge these men and women with criminal or professional misconduct would be to discourage or punish the very heroism they earlier displayed by remaining at their posts despite the hazards and to encourage early desertion as a way of avoiding censure. Taken together, these pragmatic considerations amount to a powerful justification for withholding condemnation.

2. Earlier, in Section II, I reviewed certain "yellow light" objections based on prematurity. I noted that steadfast clinicians might refrain from ending the lives of intractably suffering patients out of a worry that such an irrevocable step would be premature--other strategies might still be tried. But forced abandonment puts a full stop to such reflection. Once the patient is unattended, no further care can be on offer. When the only other option is to abandon the patient (no care at all), it may be that the best treatment would be one that beneficently and painlessly ends life. The euthanizing of black-tagged patients under conditions 1 through 3 above may represent "appropriate care under the circumstances": the least-worst option. On this argument, forced abandonment would justify euthanasia rather than merely excuse it. Not only would it be a reasonable choice: it would be the right choice.

3. But even if it could not be shown that euthanasia is the preferred option, faced with the forced choice, it remains that neither option is plainly the wrong one. The ethics literature does not authoritatively prioritize the prohibitions on abandonment and euthanasia when circumstances dictate that one of the two must give way. The two norms seem always to be considered independently, perhaps because it is not imagined that they can conflict. Clinicians who are forced to choose between the two are therefore not in violation of professional ethics, considered as a whole. If it cannot be maintained that a clinician made the wrong choice under the circumstances, there is no basis for condemnation. Notwithstanding the violation of a weighty norm, the offense, if there is one, should be excused. The circumstances forced a choice between two weighty norms, one of which had to be violated. In the absence of an accepted priority rule, neither choice should be condemned, and either choice should be excused.