End of life issues - Medical Ethics

End of life issues

Euthanasia

·        Euthanasia: 

o  = Killing someone where, because of his or her distressing physical or mental state, this is thought to be in the person‟s own best interests

o  Voluntary euthanasia: killing a competent person, when that person requests it

o   Non-voluntary euthanasia: assumed to be in the person‟s best interests – but they are not competent (eg babies, unconscious, mental incapacity)

o   Involuntary euthanasia: against the person‟s will

·        Arguments for euthanasia:

o   Autonomy and the right to die

o   Gives the person the choice to avoid pain and distress, loss of dignity, etc

·        Arguments against:

o   Hazards of voluntary euthanasia in practice: fluctuating views, pressure from family

o   Life belongs to God

o   Intrinsic value of life

·        Legal position is clear: doing anything to bring about death is murder, regardless of motive

Doctor Assisted Suicide

·        If doctor gives the patient the means (eg leaves pills by the bed) then they have committed the offence of aiding and abetting suicide, punishable by up to 14 years imprisonment under s 179 of the Crimes Act 

·        Different from euthanasia as:

o   Doctor may not approve, but may respect the patient‟s choice

o   Clearer that the patient is making their own decision without coercion

·        Reasons why doctors should be involved:

o   For:

§  They understand the medical condition (ie know the prognosis)

§  They are not an interested party (unlike families)

§  They know the best way of helping

o   Against:

§  They have a duty to preserve life

§  It might undermine confidence in the medical profession

Doctrine Of Double Effect

·        It is wrong to perform a bad act even if there are good consequences 

·        It may be possible to do a good act, even if there may be bad consequences (eg giving pain relief knowing that it may hasten death) 

·        If the consequence is virtually certain, then it is considered „intended‟ even if it wasn‟t the primary reason

Acts and Omissions

·        Legally there is a distinction between doctors not doing something (ie failing to provide treatment) and doing something (ie giving a lethal injection). However, if the person has a legal obligation to act (eg a doctor), failing to do so may be culpable 

·        Doctors have a duty to provide the necessities of life to those under their care. Failing to do so is an offence under s151 of the Crimes Act. Considering medical treatment is not indicated, or that it is not in the patient‟s best interests, is a lawful excuse 

·        Ethically, omission is generally less bad than acts of commission

Withdrawal of life-sustaining treatment

·        Is the patient competent – if so, the decision is the patient‟s. They have the right to refuse medical treatment under the bill of rights

·        Incompetent patients:

o   Any advance directive? 

o   Anyone authorised to make the decision on the patient‟s behalf (a guardian under the PPPR act or a formally appointed attorney). Patient‟s next of kin are not entitled to consent on a patient‟s behalf 

o   Decisions about whether treatment serves no therapeutic purpose are a medical decision (although see section 7(4) of code or rights re informed consent). There is no duty to continue with life-sustaining treatment where there is no prospect of recovery or any quality of life 

o   Should discuss with family

o   Discuss with colleagues (safety in numbers)

·        Cause of death will be the underlying cause, not the withdrawal of treatment 

·        Withdrawal will be treated as an omission, not an act. Courts have ruled there is no difference between turning the ventilator off and not turning it on to start with

·        Rules of thumb:

o  Intention is always to act in the patient‟s best interests

o  Err on the side of caution.  Always get a second opinion.  If in doubt, seek a court judgement

Advance Directives

·        Every competent patient has the right to refuse treatment, even if this leads to his or her death. This includes the right to leave clear instructions in case they may be incompetent in the future Þ an advance directive. Recognised in the Bill of Rights 

·        A directive is valid if:

o  The patient was competent at the time is was made

o  They were free from undue influence

o  They were sufficiently informed

o  They intend their directive to apply to circumstances which subsequently arise

·        These conditions should be tested at the point where a directive is applied