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..."