As Director for Public Relations and Ethics for County Hospital, one of your principal duties is to organize and chair the hospital’s ethics committee. The hospital administration wants you and your committee to write end-of-life policies regarding the procedures used and permitted in the hospital for care of the dying, and especially regarding right-to-die and futility.
The administration suggests the following composition for your ethics committee: a doctor, a nurse, a pharmacist, an administrator, a lawyer, an accountant, several patients, a hospice worker, a right-to-life representative, and a right-to-die representative. The agenda for the first meeting is to establish the baseline topics to be developed into a new policy handbook for County Hospital. Committee members were told to bring a list of concerns that they might have regarding end-of-life policies and procedures already in place at
Discuss at least two (2) concerns that each committee member might bring to the table during your first meeting. Your Activity responses should be both grammatically and mechanically correct and formatted in the same fashion as the Activity itself. If there is a Part A, your response should identify a Part A, etc.
Because of advances in technology, medical professionals can now save the lives of millions of people who would have died only a decade ago. Despite the many benefits of new technology, however, these advances have also placed families and physicians in the position of having to decide when patients are legally dead or when patients should die. For that reason, Americans now find themselves debating issues such as assisted suicide and euthanasia, knowing that they themselves will probably have to make decisions about one or the other in their own families.
Two premises that most ethicists agree on in regard to end-of-life issues are that the treatment of seriously disabled people should correspond roughly to the nurturance that we are obliged to provide for our very young and that the compassion shown should respect the autonomy of the individual. In other words, individuals who are of sound mind should be allowed to make decisions regarding their medical treatment, including treatments affecting the
end of life.
So, how do both medical professionals and others apply these principles in the course of their jobs? In the case of someone grievously injured but not yet cared for, such as the man in the New Testament parable who was attacked on the road from Jerusalem to Jericho, we must first ascertain whether he wants assistance. If he does, then we most assuredly have some moral obligation to help him, but we must also decide what we should do if we wish to be Good Samaritans. What if we want only to be a minimally ethical Samaritan? Then what should we do? In other words, do we help others to the full extent of our ability, even at a cost to ourselves, or do we help others only until they are safe from harm? What if the person in need refuses our assistance, choosing to die, as does the legendary elderly Native American who decides that this is a good day to die and then heads out to the wilderness? Do family members and medical professionals have an obligation to keep people alive who profess a desire to die? If we agree that we are obligated to assist the injured and ill, then we must ask whether we are obligated to help all people equally. In other words, are all lives equally valuable? Most people agree that killing a patient who does not want to be killed is murder and that murder is always wrong. But what if that patient is a killer who might kill again if he survives and is released from prison? Are doctors still obligated to save his life? If so, how much time and money should the medical profession spend trying to save the life of a murderer? Medical resources are finite, which means that money spent on one life will not be available to another
patient. Utilitarianism says that doctors should save the person who would bring the most good to the most people, but we have to ask whether we want medical professionals to decide who is more valuable than whom. What ethical system can help us decide when and how much medical assistance to give to the sick or injured? Thus far, we have addressed the ethics of giving aid to those in need; now we must address two of the most difficult issues we as a society face today. The principal controversies surrounding the end of life are voluntary active euthanasia (V. A. E.) and assisted suicide.
V. A. E. is the active taking of the life of a patient who persistently and competently asks to be killed, including patients with diseases that would allow them to live a normal lifespan, albeit in pain. Dan Brock explains the pros and cons of legalizing voluntary active euthanasia. The good consequences, according to Brock, are that it would be possible to respect the wishes of
competent patients who want V. A. E. In addition, it would reassure many people that if they wanted euthanasia, they would be able to attain it and thus be released from severe pain.
According to Brock, once death is accepted, it is often more humane to end life quickly and peacefully, when that is what the patient wants (in Card, 2004, pp. 216-217).
But V. A. E. might also permit physicians to perform euthanasia, a practice that would be incompatible with their fundamental moral and professional commitment to care for patients and protect life. Perhaps worse, patients might come to fear that a medication was intended not to treat or care, but instead to kill. In other words, patients might actually come to fear their physicians. In addition, permitting euthanasia would weaken society’s commitment to provide
optimal care for dying patients as people decided that killing seriously ill people would be cheaper and easier than caring for them. In the end, making a new option or choice available to people can sometimes make them worse off. Making euthanasia available to people as an option denies them the alternative of staying alive by default. In the end, legalized euthanasia might weaken the general legal prohibition against homicide itself (Card, pp. 217-220).
Although legalizing V. A. E. would theoretically show respect for the autonomy of the individual, studies of the consequences of legalizing of V. A. E. in the Netherlands reveal that the constraints requiring a patient’s voluntary and persistent requests for euthanasia are easily brushed aside by doctors who terminate lives without request. It would seem that euthanasia, which was promoted as a way to counterbalance physician power and to enhance the individual’s autonomy, has resulted in physicians acquiring even more power over the life and death of patients (Wikipedia, http://en.wikipedia.org/wiki/Suicide).
Brock does offer suggestions for protecting against abuse of V. A. E.:
1. The patient should be provided with all relevant information.
2. The patient’s request for euthanasia should be stable and enduring.
3. All reasonable alternatives must have been explored for improving the patient’s
quality of life.
4. A psychiatric evaluation should ensure that the patient’s request is not the result of a treatable psychological impairment. (Card, p. 221)
Assisted suicide is different from euthanasia in that persons kill themselves with the assistance of another. Assisted suicide is usually undertaken away from health care facilities, which actively discourage suicide. There are three degrees of assisted suicide. At the lowest level, one could assist a person in suicide by furnishing them with information about how to do it, perhaps by giving them access to the works of the Hemlock Society. At an intermediary level, one can provide the means for suicide by writing prescriptions for lethal amounts of medication.
At the most involved level, one could supervise or directly aid the suicide by inserting an intravenous line and instructing the patient on how to start a lethal infusion (Watts & Howell in Card, p. 233).
Actively killing persons in unremitting, untreatable, and terminal pain who ask to die is forbidden by law, but just as physicians have ended the lives of the terminally ill for centuries, today they terminate life by administering very high doses of morphine with the professed desire to alleviate pain. Is this murder? Is there an ethical difference between administering enough pain medication to cause death and shooting a terminally ill patient, as one mother did her son?
For patients who want to die or have previously indicated their opposition to extraordinary life support, removing support systems is an accepted practice by the AMA and in U. S. law. This practice is sometimes called voluntary passive euthanasia. There exists an argument that the distinction between removing life support and active euthanasia is merely a legalistic one and that passive euthanasia sometimes inflicts more pain than active euthanasia. David Watts and Timothy Howell (as cited in Card, 2004) agree with the arguments against euthanasia and believe that direct participation in suicide by inserting catheters, for example, goes too far, being a short step from active euthanasia. Such direct participation would invite “potential abuse of vulnerable persons, mistrust of physicians, and diminished availability of supportive services for the dying. . . . These arguments [however, are much weaker] when applied to more limited forms of physician-assisted suicide” (p. 234). Watt’s and Howell’s reasoning is based on the idea of autonomy. They believe that providing someone with the
means to die and allowing that person to make the decision to end his or her life respects the autonomy of the individual. It also assumes that the patient is mentally and emotionally capable of making a clear decision and that the patient is aware of all of his or her options. Timothy Quill (as cited in Card, 2004) recounts how he aided a patient who insisted for her own reasons on committing suicide. His account demonstrates how assisted suicide can lead to a familial and personal dignified death. Examples such as this point out the essential difference between private morality and public ethics. A society that sanctions suicide and
euthanasia might well weaken its commitment to life so that even those who have no wish to die find that they have no control over the termination of their lives. Yet, in the privacy of our compassionate and loving lives, we may feel justified in performing acts that are forbidden by the rules of ethics and laws. Public policy reflects this social and personal divide in many ways: decisions not to prosecute, jury nullification, ignoring the over-administration of morphine drips, and strictly honoring doctor-patient privacy. Public policy may also legitimize V.A.E. or physician assisted suicide.
But what about patients who cannot express an opinion because they are in a persistent vegetative state, an issue that has been on the front page of every paper in America in the past two years, primarily regarding the Terry Schiavo case in Florida. Actively killing patients who cannot communicate their wishes is forbidden by the rules of the American Medical Association (AMA) and by most national and state laws. Nevertheless, courts have allowed family members
to deprive comatose patients of oxygen or food, thereby killing them. The question the court tries to answer is whether the patient is brain dead. Some Americans, however, have protested these decisions, including family members who have sued to keep such patients alive. Most of these cases do not end up in court, however. Physicians admit that many in their profession have secretly ended the lives of terminally ill patients for millennia. One justification for this
behavior, especially in the days when the doctor/patient relationship was more personal than it is today, was the virtuous person argument: the virtuous doctor, in consultation with patients and their families, would make the compassionate and wise decision. In our age of forced transparency and insistence on rules, however, private decisions to end the lives of comatose
patients often cause public consternation because these cases highlight the complexity of modern life and the divide between religious and ethical views of Americans. (See, for example, the case of Robert Latimer www/cbc/ca/news/background/latimer.) And what about patients who request
extraordinary life-prolonging measures yet lack funds to pay for those measures? The larger questions is, What obligation does society have to pay for medical treatment of those who do not have the means to pay, even if they lack the means because of the choices they have made throughout their lives? Who should be allowed to make end-of-life decisions for the comatose or
the indigent? Families? Hospitals? Insurance companies? Governments?
We all want rules to guide us in making decisions. In our law-and-order moments, we believe that rules must be followed to the letter. In our more liberal moments, we believe that laws are made to cover the vast majority of cases, but that they do not apply in every situation. In that liberal mindset, we continue to follow the rules for the good order of society, but retain
the option of bending a rule in certain extreme situations. We keep our rule violations as private
as possible and accept the possible prosecution for our moral independence.
Uncertainty regarding end-of-life decisions can create pain, conflict, and drawn out legal proceedings. In general, if it can be shown that the patient had expressed a desire not to maintain extraordinary procedures, then hospitals and courts allow the discontinuance of treatment and patients are allowed to die a natural death. For that reason, many people now perform advance directives and do-not-resuscitate orders that clearly state the kinds of life-saving measures that they do or do not want. Advance directives are of two kinds: a living will and durable powers of attorney for health care. Living wills describe the kind of treatment people desire in certain situations, but they do not allow people to select someone to make decisions for them. Durable power of attorney states whom the patient has chosen to make health care decisions for them. A
do-not-resuscitate order is a request not to have cardiopulmonary resuscitation (CPR) if one’s heart stops beating (http://familydoctor.org/x1625.xml).
A different kind of controversy arises when a patient who has expressed a desire to have all available measures used to keep him or her alive is now hopelessly comatose. Are doctors and hospitals obliged to continue providing measures and care that they deem useless for restoring a patient to consciousness? How are they to deal with this issue of “futility”?