Introduction
The care of patients near the end of life can be ethically challenging. Physicians and other health care professionals may find certain concepts vague and hard to understand. Furthermore, there must be a balance between two extremes: a treat-at-all-costs vitalism on the one hand, and a too-rapid withdrawal of potentially beneficial treatments on the other. A number of ethical theories and principles are relevant when considering treatment decisions at the end of life.
Sanctity of Life Doctrine
The argument underpinning this doctrine is that all human life has worth and therefore it is wrong to take steps to end a person’s life, directly or indirectly, no matter what the quality of that life. This is in keeping with both traditional codes of medical ethics and a general perception of what doctors and other health professionals should do, that is save and preserve life. One challenge to this principle in the context of health care is to ask should life be preserved at all costs. Is there no place for consideration of quality of life? One of the problems with considering quality of life is the question of how this is defined and by whom. An objective view of someone’s life may be very different to the view of the person who is living that life. However, this problem does not remove the challenge to the sanctity of life doctrine. There may be some circumstances where a person’s quality of life, however defined, is so poor that it should not be maintained even if it is possible to do so. Some ethical arguments have been developed to address this challenge.
Video: Death with Dignity | Grace Pastine | TEDxStanleyPark.
Acts /Omissions Distinction
This distinction argues that there is a difference between actively killing someone and refraining from an action that may save or preserve that person’s life. Thus it is morally wrong to push someone into a river to their death but we may not have a moral duty to leap into the river to save someone who is drowning. In a medical context this distinction would mean that a doctor could not give a patient a lethal injection to end his/her life, whatever the circumstances, but could, withhold treatment that may sustain it. Withholding treatment would only be permissible if the patient’s quality of life was so poor, and the burden of treatment so great, that it would not to be in the patient’s best interests to continue treatment. For example, it might be permissible not to ventilate a patient if he/she was in chronic respiratory failure, or not to use tube feeding if he/she was in a permanent vegetative state. Doctrine of Double Effect
The doctrine of double effect argues that there is a moral distinction between acting with the intention to bring about a person’s death and performing an act where death is a foreseen but unintended consequence.
The doctrine of double effect allows that performing an act that brings about a good consequence may be morally right even though the good consequence can only be achieved at the risk of a harmful side effect. Prescribing pain relieving drugs which in large doses shorten the life of a terminally ill patient is often used as an example of double effect. The intention is to relieve pain and the foreseen but unintended consequence is that the patient’s life will be shortened. Current practice in palliative medicine and the range of drugs available may reduce the appropriateness of this doctrine.
Respect for autonomy
The principle for respect for autonomy acknowledges the right of a patient to have control over his or her own life, including decisions about how his/her life should end. Thus a competent person should be able to refuse life saving treatment in both current situations and future foreseeable situations. Should respect for autonomy mean that a person can request assistance in ending his/her life? Some would argue that this is the case but as assisted suicide is currently illegal in the UK this is not an issue that a clinical ethics committee should need to consider. Does respect for autonomy mean that a patient can request treatment that the clinician does not think is in his/her best interests, or treatment that is futile? In these situations the principle of respect for autonomy comes into conflict with other ethical considerations, such as preventing or avoiding harm, or distributive justice.
A duty to act in the patient’s best interest (Beneficence)
The duty of beneficence, that is to act in a way that benefits the patient, is an important ethical principle in health care. In treatment decisions at the end of life the dilemma often revolves around what course of action will be in the patient’s best interests. It is difficult to see how death can be a benefit or in the patient’s interests, but in some circumstances, if existing quality of life is so poor, or treatment is very burdensome, then the balance of harms and benefits may suggest that continuing treatment is not a benefit to the patient.
A duty not to harm (Nonmaleficence)
The concept of nonmaleficence – an obligation not to inflict harm intentionally, is distinct from that of beneficence – an obligation to help others. In codes of medical practice the principle of nonmaleficence (primum non nocere) has been a fundamental tenet. However, in the context of health care it can sometimes be difficult to comply with this principle depending on the definition of harm. Many medical treatments may have harmful side effects but save or improve lives. In end of life decisions the question of how much harm is caused by the treatment needs to be considered, as does the question of whether death itself is always a harm.
End of Life Issues
Video: How Doctors Tell Patients They’re Dying | Being Mortal | FRONTLINE.
The care of patients near the end of life can be ethically challenging. Physicians and other health care professionals may find certain concepts vague and hard to understand. Furthermore, there must be a balance between two extremes: a treat-at-all-costs vitalism on the one hand, and a too-rapid withdrawal of potentially beneficial treatments on the other. Therefore, we must aim to reach conceptual clarity.1
A terminal condition is a disease or disease process that will result eventually in a patient’s death, no matter what treatment is given. Of course, this may include cases where death is inevitable but far off, as in patients with cancer who live for years with their disease. On the other hand, the expression imminent death is used when death is expected within a short time, usually days or weeks.2
The word euthanasia comes from two Greek words: eu for “good,” and thanatos for “death.” Thus the term means a “good” or “gentle” death.3 Active euthanasia is the overt, deliberate killing of a patient, e.g., by injecting an overdose of morphine or by giving potassium chloride to stop the heart. Passive euthanasia refers to the withdrawing or withholding of treatment, while the disease process takes its course to cause death.4 In other words, the distinction is between killing and letting die, but the intent in both is the patient”s death.
Most would condemn active killing. “Letting die” may seem to be more acceptable, though it can be just as unethical as active killing. Some ethicists would thereby argue that there is no morally relevant distinction between active and passive euthanasia.5 However, this oversimplifies the reality of medical care. “Letting die” may be morally justifiable in medicine if a particular intervention is truly futile, or if a patient or her authorized surrogate refuses it.3 Thus, the medical cause of death does have moral relevance, though not in and of itself. For these reasons, the term passive euthanasia has only added confusion to the ethical debate, and should be discarded.
Another way to look at euthanasia involves three categories: voluntary, nonvoluntary, and involuntary. Voluntary euthanasia is the act of bringing about a competent patient”s death at his request. Nonvoluntary euthanasia means ending the life of an incompetent patient, usually at the request of a family member, as in the Karen Quinlan case. In 1975, the New Jersey Supreme Court granted Miss Quinlan”s father the right to authorize removal of the respirator from his comatose daughter.6 Involuntary euthanasia means taking the life of an competent patient who does not wish to die.7 A moment”s reflection will demonstrate that these are not morally helpful distinctions. As mentioned earlier, the active taking of a patient”s life is usually considered wrong, even if a patient requests it. The focus here is on the agent who gives consent, rather than on the ethical merits of the act of killing or letting die. Physician-assisted suicide is a variation of voluntary active euthanasia, where the agent who causes the death is the patient herself, with means provided by the physician.
Finally, the omission v. commission argument is frequently cited in making a distinction between withholding treatment, i.e., not starting it, versus withdrawing treatment, i.e., stopping an intervention already begun. Historically, the latter has always been more difficult in medicine than the former, though this is probably more psychological than real. Bioethicists Beauchamp and Childress call the distinction “both irrelevant and dangerous.”7
Another aspect of end of life decisions involves terms relating to neurological functioning. The Terri Schiavo case fostered a great deal of discussion around the diagnosis persistent vegetative state (PVS). PVS is a state of severe brain injury, characterized by wakefulness (i.e., the presence of sleep-wake cycles), but no awareness of oneself or the external environment. This is due to severe damage to the cerebral cortex, with preservation of the brainstem. Patients in PVS have their eyes open, and may make non-purposeful movements. The presence of “sustained visual pursuit”� (the ability to track movement) or “visual fixation”� (the ability to sustain gaze upon an object) should cast doubt on the diagnosis of PVS.8,9
The minimally conscious state (MCS) is a closely related diagnosis, but differs from PVS in that MCS applies to patients who are awake and show minimal signs of responsiveness. There is greater activity of the cerebral cortex in MCS patients, and this may be dependent on the “emotional relevance” of the external stimulus.10 Both PVS and MCS are clinical diagnoses; in other words, such determinations are made at the bedside from careful examinations repeated on several occasions.
Finally, there is the state of brain death, or more accurately, death by neurological criteria. Brain death is not as controversial as PVS and MCS, and is well accepted by most physicians. According to this definition, death has occurred after massive neurological injury to both the cerebral cortex and the brain stem. Clinically, this means that no reflexes are present, there is no spontaneous breathing (the patient is ventilator dependent), and an electroencephalogram is isoelectric or “flat,” after two readings taken 24 hours apart.11 Under these circumstances, it may be ethically appropriate to discontinue life support or consider organ donation.
References
1. Portions of this article were excerpted from: Sullivan D. “Euthanasia versus letting die: Christian decision-making in terminal patients.” Ethics and Medicine. 2005;21(2):109-18.
2. Kilner JF. Life on the Line. Bannockburn, IL: Center For Bioethics and Human Dignity; 1992.
3. Feinberg JS, Feinberg PD. Ethics For a Brave New World. Wheaton: Crossway Books; 1993.
4. Kilner JF. “Foregoing Treatment.” In: Kilner JF, Miller AB, Pellegrino ED (eds). Dignity and Dying: A Christian Appraisal. Grand Rapids: William B. Eerdmans, 1996:69-83.
5. Rachels J. “Active and Passive Euthanasia.” In: Beauchamp T, Perlin S (eds). Ethical Issues in Death and Dying. Englewood Cliffs, NJ: Prentice-Hall, 1978.
6. Healthcare Ethics www.ascensionhealth.org/ethics/public/cases//case21.asp. Accessed October 3, 2006. Ascension Health, 2003.
7. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Fifth ed. New York: Oxford University Press, 2001:121.
8. “Medical Aspects of the Persistent Vegetative State (Part I).” New England Journal of Medicine. 1994 May 26, 1994;330(21):1499-508.
9. “Medical Aspects of the Persistent Vegetative State (Part II).”New England Journal of Medicine. 1994 June 2, 1994;330(22):1572-9.
10. Laureys S, Perrin F, Schnakers C, Boly M, Majerus S. “Residual Cognitive Function in Comatose, Vegetative, and Minimally Conscious States.” Current Opinion in Neurology. 2005 December, 2005;18(6):726-33.
11. Sullivan J, Seem D, Chabalewski F. “Determining Brain Death.” Critical Care Nurse. 1999;19:48-52.
12. Clinical Ethics Network. (2016). End of Life Issues and Ethics. Retrieved from: http://www.ukcen.net/ethical_issues/end_life
13. Sullivan, D. M. (2016). End of Life Decisions 101. Retrieved from: http://www.bioethics.com/end-of-life-101