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Medical EthicsEnd-of-life Issues
&Euthanasia
Srivieng Pairojkul, MD.Department of Pediatrics
Faculty of MedicineKhon Kaen University
End-of-life Issues & EuthanasiaGoals • To understand conflict
between a physician’s duty to save life and other values.
• End-of-life decision making• Reflect on who should make
decision and how.• Know the definition and type
of euthanasia..
How we get there• Review ethic
theories and principles
• Case analysis base on ethic theories and principles of ethics.
Ethics and Medicine• Since medicine deals with the life and
death of people, ethical problems naturally arise.
• Doctors face ethical problems everyday.• But how well equipped are they to deal with
the issues?• Basic principles:
– Do No Harm. (Non-maleficence)– Do Good (Beneficence)– Be Fair (Justice)
Ethic Theories
UtilitarianismThe greatest happiness principleResource allocation Kantianism
Duty-based theories “Deontology”Duty to save life
Case Analysis in Clinical Ethics
Medical Indication
Patient Preferences
Quality of LifeContextual Features
Issues in End-of-Life Care
• Ethical principles• Shared decision making• The right to refuse medical treatment• Forgoing treatment on the basis of
medical futility• Killing vs allowing to die
Principles of Medical Ethics
• Respect for patient autonomy• Beneficence – “Benefit the sick”• Non-maleficence – “Do no harm”• Justice – Require social policy level
Shared Decision MakingDecision should be shared between physician & patient
PhysicianInform the treatment optionson the best medical interest
PatientReceive information
Chose treatment
Accept doctor ‘srecommendation
Refuse treatment
Right to Refuse Medical Treatment
• Patient with decision-making capacity• Patient without capacity but had earlier
expressed treatment preferences for EOL care• Patient without capacity, had made no prior
expression• Patient who never had the capacity to make
treatment decisions
Patient without decision making capacity
Proxy decision making make “substituted judgment”
• Preservation of life• Prevention of suicide• Protection of third parties• Preservation of the ethical integrity of
medical profession
Right to Refuse Medical Treatment
State courts have identified social interests that must be balanced against a person’s right to refuse treatment
Basis of Futility• Post-hoc futility• Predictive futility
- Conceptual futility - Brain death- Probabilistic futility - survival chance- Physiologic futility - Doctor-patient goal disagreements –
value differences
Killing vs Allowing to DieWhen discontinue life-sustaining treatment
Causing the patient’s deathvs.
Allowing the patient to die
Withhold / withdraw life support
Do Not Resuscitate Orders
• When CPR is judged to be no medical benefit (medical futility)
• When the patient with intact decision making capacity clearly indicates that he/she does not want CPR
CPR – Set of specific supportive medical procedure
When can CPR be withheld ?
• What if CPR is not futile, but the patient wants a DNR order ?
• What if the patient is unable to say what his/her wishes are?
• What if the family disagrees with DNR order?
* Respect autonomy
* Write DNR order only with patient/family agreement.
* Advance directive (Living will)* Surrogate decision maker
Surrogate Decision Makers• Legal guardian with health care decision-
making authority• Individual given durable power of attorney
for health decision• Spouse• Adult children of patient (all in agreement)• Parents of patient• Adult siblings of patient (all in agreement)
PeacePeaceFreedomFreedomFreedomAestheticAestheticHuman beingHuman being
The brain-dead patient and the family’s dilemma
A 15-year old patient, suffered major injuries is now brain dead. The parents have been explained everything. They do not want to let their loved one go, and want to continue treatment.
• Can physicians take a decision to switch off the ventilator if it is needed by another patient?
****• Legal V.S. ethical issues
BeneficenceAutonomy
Non-maleficenceJustice
Brain deathPatient’s suffering
Resource allocation
KillingFamily’s decisionFamily’s grief
Continue life support Withdraw life support
The terminal cancer patientA 50-year old man with metastatic cancer. You know that another trial of chemotherapy may prolong his life for several months, but he will suffer enormous pain. The family had already spent 100,000 Bahts for the treatment. He is poor and has 3 children with a wife who does not earn.
• Will you offer this treatment to the family ?****
• If you had offered this treatment to the family , what will be your decision- If the family want to continue the treatment ?- If the family want to go back home?
BeneficenceAutonomy
Non-maleficenceJustice
• Disease is incurable• Patient’s suffering• Burden to family• Resource allocation
• Truth telling – offer treatment• Family values• Family’s decision
Provide treatment according to family’s value Not offer the treatment
Baby Theresa
Theresa Ann Campo Pearson Anencephalic infant born in Florida in 1992
Parents volunteered her organs for transplant
Is it justify to remove the infant’s organs,causing her immediate death to help
other children?****
Baby Theresa• The benefits argument• The argument that we should not use
people as means• The argument from the wrongness of
killing
Jodie and MaryIn August 2000, a young women from Gozocarrying conjoint twins, she was transferred
to England to have the babies delivered
The babies shared one heart and one set of lung, the babies will die if operation was
not performed to separate the babies
Parents are Catholics, refused permission for the operation “If it’s God’s will that both
of our children should not survive then so be it”****
Jodie and Mary
The courts granted permission and on November 6th the operation was performed
Jodie lived and Mary died
• The argument that we should save as many as we can
• The argument from the Sanctity of Human Life
Jodie and Mary
Please Let Me Die!
Dax’s Case
The Case of Dax Cowart• Due to a propane gas explosion a 25-year-
old, single male (Dax) was critically injured.• Dax suffers from horrendous 2nd and 3rd
degree burns on more than 68% of his body.• Both eyes, both ears and both hands are
damaged beyond repair.• Large doses of narcotics are required to
minimally reduce the excruciating pain he experiences
The Case of Dax Cowart• Repeatedly wishes he had died in the explosion.• Continually begs that treatment be discontinued
and that he be allowed to die.****
• Despite this demand the wound care was continued, skin grafts were performed, and nutritional and fluid support were provided
• He was discharged totally blind, with minimal use of his hands, badly scared, and dependent on others for assistance
Theresa Marie "Terri" SchiavoShe collapsed in her home, and experienced cardiac arrest leading to 15 years of institutionalization and a diagnosis of persistent vegetative state. In 1998, her husband and guardian, petitioned the Court to remove her feeding tube. Her parents, opposed this.
The court determined that Terri would not wish to continue life-prolonging measures. The battle stretched on for seven years and included involvement by politicians and advocacy groups.
****
What is Good Death ?What is Good Death ?
What is Happening in Modern Medicine ?
• Huge technological advances
• Runaway healthcare costs• Medicine getting more
impersonal• Subspecialization on
organ systems• Quantity rather than
quality of life
How People die?
People do not die in the places they wish
or with the peace they desire.
Many die alone, in pain, terrified, mentally unaware, without dignity, or
feeling alienated
What is a Good Death ?
Common Ideal Death Scenarios
Mercy KillingsA Good Death ?
Tracy LatimerTracy Latimer, a 12-year-old victim of
cerebral palsy, was killed by her father in 1993
Mr. Latimer was tried for murder. The juryfound him guilty only second-degree murderand ignore the 25-year sentence. He was
sentenced to one year in prison
The supreme court of Canada stepped in and ruled that the mandatory sentence must
be imposed, Mr. Latimer is now in prison,serving the 25-year term
****
Robert LatimerRobert Latimer (born March 13, 1953) is a
Canadian farmer sentenced to life imprisonment without the possibility of parole for ten years for the murder of his daughter Tracy (born November 23,1980), which occurred on October 24, 1993.
This act sparked a significant national controversy on the ethics of mercy killings.
From Wikipedia, the free encyclopedia
Jack Kevorkian
Between 1990 and 1998, Kevorkian assisted in the suicide of nearly
one hundred terminally ill people
Euthanasia( From Greek: ευθανασία)
A practice of terminating the life of a person or ananimal because they are perceived as living an
intolerable life, in a painless or minimally painful way either by lethal injection, drug overdose,
or by the withdrawal of life support.
Euthanasia
• Active euthanasia – Physician assisted suicide
• Passive euthanasia - Hastening the death of a person by altering some form of support and letting nature take its course.
A machine that can facilitate Euthanasia through heavy doses of drugs.
20 mg/kg thiopental sodium IV 20 mg pancuronium dibromide (Pavulon)
"...And death shall be no more; Death, thou shalt die!""...And death shall be no more; Death, thou shalt die!"
"One short sleep past, we wake eternally...""One short sleep past, we wake eternally..."
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