J.S.

Mill's Libertarianism to Explain Medical Ethics: Two Illustrative Cases on

Euthanasia
By Dominique Angela Juntado

Libertarianism generally pertains to a collection of political philosophies

possessing the common themes of individual liberty. The ideals focus on policies
in favor of extensive personal liberties. A working definition of libertarianism as
had been provided by American Heritage Dictionary 2000 is written as: the
minimization of the role of the state. Roberts [1974] takes libertarianism to be
defined by following two points: the first being that free human actions are not
covered by universal laws, and secondly, that there is the recognition of the
individual as the agent in control of his free human actions.
Sprinkle [1937] recognizes that course of actions possess three components
before their realization. First, the agent is the entity endowed with the power of
choice. Secondly, the agent has a mental blueprint charting out a set of possible
choices he may pursue. One of these is the most significant for him, that which he
has the higher probability of choosing. He has a notion of that desired choice.
Last is the recognition of the fact that there is virtually nothing which may
prevent the agent from achieving his desired goal, the materialization of the
choice.
Libertarians do not always share common footing in terms of perspective.
Goldberg [2001] raises that there is a broad, general division of libertarians
comprising of the consequentialists and rights theorists.
Differentiation
Rights theorists oppose "initiation of force and fraud," taken against a person
who has not initiated physical force, threat, or fraud (many of these are
individualist anarchists). Consequentialist libertarians, however, accept those
actions, which they believe result in the maximum liberty even if it requires some
initiation of force. A particular criticism of libertarianism may not apply to both
forms. Common ground present between divisions is that there is the act of
choice and decision-making.
To gain its theoretical essence, the concept of liberty will be derived from the
perspective of John Stuart Mill’s essay On Liberty.
Individual Liberty had gained ground initially through John Stuart Mill’s
discourse, and was later expanded by other theorists such as Berlin and Nozick,
just to name a few. On Liberty is an acclaimed treatise on Civil or Social Liberty:
the nature and limits of the power which can be legitimately exercised by society
over the individual. His recognition that this is a question seldomly raised and
hardly addressed, yet is a profound influence in practical controversies, is
significant. Society has always been divided between stands in certain issues.
Individual liberty is the recurring theme present in his works. Mill maintained
that an individual may do anything he or she pleases provided that the actions of
the individual do not produce the aftermath of harm to others. In his discussion
on the role of authorities in liberty, he writes that governments have no right to
interfere in any affair of the individual, regardless of the enactment whatever
laws or ordinances have been formulated with intensions of promoting general
welfare. He fervently contends that the sole reason for governmental existence is
for protection. This, so that the individual may have the benefits of safety during
time of peace, defense during war, and security from fraudulence and or cheating.
Theory to Practice
We begin with a basic note. The most practical application of liberty is
pertinence to the aspects of life and rights. To place into some effect or
exemplification the application of J.S. Mill’s concept of liberty, we shall examine
it from the vantage point of its application to medical ethics.
A. Medical Ethics
Primarily a field of applied ethics, it is the study of moral values and
judgments as they may apply to medicine. It encompasses its practical
application in clinical settings.
A.1 Values in Medical Ethics
Wikipedia provides a listing of six values that comprise the philosophical
framework of medical ethics.
a.1.1 Salus aegroti suprema lex (Beneficience)
A practitioner should act in the best interest of the patient.
a.1.2 Primum non nocere (Non-maleficence)
“First do no harm”
a.1.3 Voluntas aegroti suprema lex (Autonomy)
The patient has the right to refuse or choose their treatment.
a.1.4 Justice
Concerns the distribution of scarce health resources, and the decision of
who gets what particular treatment.
a.1.5 Dignity
The patient and the physician both have the right to dignity.
a.1.6 Truthfulness and Honesty
The concept of informed consent has increased in importance since the
historical events of the Nuremburg Trials and the Tuskegee Syphilis Study. These
will be expanded later.
The conflict of moral values results in ethical dilemma.
A.2 Synthesis
The following line reflects John Stuart Mill’s approach towards the
individual as an autonomous body:
over himself, over his own body and mind, the individual is sovereign
This statement implies that the individual has control over his person. That same
characteristic of control permits him to do as he pleases to himself, through his
own consent. This is in line with value a.1.3 Voluntas aegroti suprema lex where
the decision of whether or not to be treated and the choice of treatment is in the
end up to the patient.
The principle of Autonomy recognizes the rights of individuals to self
determination. This is rooted in society’s respect for individuals’ ability to make
informed decisions about personal matters. Autonomy has become more
important as social values have shifted to define medical quality in terms of
outcomes that are important to the patient rather than medical professionals.
However, there are times that certain controversies test the validity and strength
of this notion. This is through governmental interference in the promotion of the
Harm Principle, which Mill had discussed in Chapter One of his treatise:
...in interfering with the liberty of action of any of their number, is
protection. That the only purpose for which power can be rightfully
exercised over any member of a civilized community, against his will,
is to prevent harm to others.
Naturally, harm affects the right to life. Taken into the context of medical
ethics, the controversial issue is if there is the right to life, there must also be the
right to death. It is not merely the issue of death that is the heart of the matter.
What manages to raise brows is the means to achieve the act.
A.2.1 Physician-Assisted Suicide
Also known as euthanasia, it is addressed both as a ‘merciful means of
achieving death’ and as ‘a form of murder’. Euthanasia may either be voluntary or
involuntary. The former involves the consent of the agent in the performance of
the act. The latter is usually upon the decision of immediate members of the
family or persons closely associated to the individual who does not have the
capacity to make the decision.
The common and accepted means to achieve physician-assisted suicide is
through either the cease of treatment or the administration of certain medication
which when over-maximizing dosage, knowingly results in death. An example of
such would be morphine, initially serving the purpose of pain-relief but may be a
cause of death if having administered a high dosage. This is considered as a
double effect.
Stanford University provides an overview of voluntary euthanasia. In
terms of reasons given:
1. Choice
2. Quality of Life
3. Economic Costs and Human Resources
A.2.1.1 Case Study No. 1 – ‘Dying is not a Crime’
American pathologist Jack Kevorkian is notorious for his public
declaration of a patient’s right to die (terminal condition) through the means of
physician-assisted suicide. His means of promoting his idea is through
advertising “Death Counseling” in Detroit newspapers.
Kevorkian administers his treatment through original inventions to carry
out the task of ‘mercy-killing’. He was able to design two devices: (1) Thanatron.
It is attached to the patient, euthanasia drugs are passed into the patient’s
bloodstream through the use of an IV, with the fashion of a push-button
mechanism, it is up to the patient if he or she wishes to continue the act. This
device alone illustrates that the role of the physician is solely confined to
assistance, and the decision is of the patient. (2) Mercytron also makes use of a
push-button mechanism. The patient is to wear a gas mask, and carbon
monoxide is inhaled through the apparatus.
 The Thomas Youk case was the convicting piece. Youk was a 52 year old
adult male in the final stages of ALS. He voluntarily undergone the process in
belief of Kevorkian’s cause. His condition did not prevent him from possessing
complete decisional capacity. After having provided a fully informed consent,
Kevorkian administered the lethal injection. The procedure was recorded via VHS
and was presented in CBS’s 60 Minutes. Though there was informed consent, it
was material capable of convicting Kevorkian due to the final lines he spoke in
the video which challenged authorities to stop him from his tasks. This was an
implication of murder.
The common notion is that euthanasia comes into contradiction with
Primum non nocere, or the Hippocratic Oath. What is being overlooked is that in
some cases it is considered the opposite. Death is preferred over the unbearable
-ness of the pain. What must be taken into consideration is the decision of
whether or not to prolong the patient’s agony. More harm is done in the attempt
of maintaining life than giving death.
Venturing over to its evaluation in terms of Mill, euthanasia may be accepted on
grounds that there is consent (either by the individual undergoing the process or
the agent responsible for the individual) The autonomy of the individual is
invoked here. The individual is the agent of the choice, mindful of his or her
options and their effects, and with recognition that the desired outcome may be
achieved.
From the situation, there is more good resulting from the act than harm.
The pain and suffering a person feels during a disease, even with pain relievers
can be incomprehensible to a person who has not gone through it. Even without
considering the physical pain, it is often difficult for patients to overcome the
emotional pain of losing their independence. Moreover, despite modern
painkillers, there is little available to deal with the problem of ‘breathlessness’,
which many ailing patients feel they will suffocate. On practicality – in many
countries there is a shortage of hospital space. The energy of doctors and hospital
beds could be used for people whose lives could be saved instead of continuing
the life of those wish to die which increases the general quality of care and
shortens hospital waiting lists. It is a burden to keep people alive past the point
they can contribute to society.
The government does not have the right to meddle with the affairs of the
individual. However, it has inherent powers of regulation. Though euthanasia is
not a universally accepted practice, the role the state plays in this matter is to
pass bills containing the decisions as to whether or not treatment is to be
continued.
A.2.1.2 Terri Schiavo
A notable example would be the case of Terri Schiavo. Theresa Marie Schiavo,
from St. Petersburg, Florida, suffered from brain damage. Her food intake was
only possible through a feeding tube, her dependency. Her experience of
respiratory and cardiac arrest resulted in extensive brain damage, a diagnosis of
persistent vegetative state and fifteen (15) years of institutionalization. Husband
Michael Schiavo petitioned for the removal of her feeding tube. Parents Robert
and Mary Schindler contested, reason being that Terri was conscious. The
Schiavo controversy was the product of court decision that Terri would not wish
to continue life-prolonging measures [Levesque: 2003].
This controversy had extended into a duration of seven (7) years, further
highlighted with the involvement of politicians and advocacy groups comprising
of the prolife and disability rights classification [Easton: 2005].
On 15 October 2003, Schiavo’s feeding tube was removed. It was within a week’s
time that Schindler’s final appeal was exhausted. Terri’s Law was passed. This
had given Governor Jeb Bush the authority of intervention in the case. Bush’s
decision was to reinsert the tube. Schiavo was removed from the hospice and
transported to Morton Plant Rehabilitation Hospital in Clearwater, where her
feeding tube is to be reinserted [Bury: 2005]. Following this was Schiavo’s return
to the hospice. It was included in the legislation that a guardian ad litem (GAL)
be appointed. This was Dr. Jay Wolfson, to ‘deduce and represent the best wishes
and best interests’ of Schiavo, and report them to Governor Bush. The report of
Wolfson did not change Michael’s role as her legal guardian [Wolfson: 2003].

Comments on Libertarianism
It may be disputed that the reality that the promotion of personal freedoms
to the excessive extent is sure to encourage irresponsible and dangerous behavior
on the part of individuals who practice. There is an abuse of this theory. Its
application is applied far too generously. Though it may be aspired for the
government to take on a hands-off approach towards the actions of its citizens, it
would jeopardize public safety, the primary rationale behind the existence of
government, its inherent police power. The government in this sense is to
regulate activity. There can be no such thing as perfect freedom.
 REFERENCES

Journals
H. C. Sprinkle, The Logic of Libertarianism, The Journal of Philosophy, Vol. 34,
No. 21. (Oct. 14, 1937), pp. 574-580.
Roberts, Lawrence D., Libertarianism and Statistical Laws, Noûs, Vol. 8, No. 2.
(May, 1974), pp. 195-199.
Levesque, William R., "Schiavo's wishes recalled in records", St. Petersburg
Times Online, November 8, 2003.
Easton, Nina, "Rights groups for disabled join in fight" Boston Globe, March 23,
2005.
Transcripts
Bury, Chris. "Transcript: Michael Schiavo on 'Nightline': Husband at the Heart of
the 'Right to Die' Case Speaks to Chris Bury," ABC News, March 15, 2005.

Wolfson, Jay Dr.PH, JD,"A Report To Governor Bush and the 6th Judicial Circuit

in the Matter of Theresa Marie Schiavo", Abstract Appeal Legal Blog, December 1, 2003 (P.10/38, Paragraph
5)
E-texts
Mill, John Stuart, On Liberty E-text
http://etext.library.adelaide.edu.au/m/mill/john_stuart/m645o/index.html, accessed 22 February 2008,
2340 HRS.

Webpages
Stanford University
http://plato.stanford.edu, accessed 23 February 2008, 0400 HRS.
Wikipedia, the Free Encyclopedia
Medical Ethics
http://www.wikipedia.org, accessed 23 February 2008, 0410 HRS.
Names Database
http://www.nndb.com/people/272/000023203, accessed 23 February 2008, 0330 HRS.
American Heritage Online Dictionary
http://www.AHD.com/, accessed 23 February 2008, 0315 HRS.