Medical advances that are quite recent, have overshadowed it’s long held ethical belief of compassion and care. The main issue has been the appropriate use of technological advances at the end of life. Should these advances be used on every patient despite the chance of an undesired outcome? If not, what guidelines should be put into effect for the use and non-use of medical interventions during this time? This paper will address the ethical issues that guide medical practice and focus on end of life ethical issues such as assisted suicide, the difference between killing and allowing to die, life sustaining measures, and medical futility.
The main issue in the care of the dying patient is the proper use of life sustaining interventions. In some cases, there is very little to no benefit to be gained by these interventions (Walker, 2017). Commonly, when the benefits are overpowered by the potential harms or risks of medical treatment, it is determined as not appropriate for the patient (Walker, 2017). Who has the ultimate authority is the main question that has left many wandering if the decision should be made by the physician or on a policy level (Walker. 2017). From an ethical standpoint, the patient is the one to make the decision regarding life sustaining interventions based upon autonomy (Walker, 2017).
In many cases, ethical treatment decisions should be done between the patient and provider. The physician is obligated to inform the patient of the treatment options available and to also recommend which treatment he or she believes is in the patient’s best interest (Walker, 2017). The patient then accepts the provider’s recommended course of treatment and consents, chooses a treatment plan other than what was recommended, or chooses to not seek treatment altogether (Walker, 2017). In every case mentioned, the provider has fulfilled their ethical obligation to give every option available to the patient (Walker, 2017). The patient, then uses their autonomy in choosing or rejecting treatment. This process may result in conflict between the patient and provider but in most cases of treatment refusal the patient’s autonomy will prevail (Walker, 2017). The provider may still attempt to persuade the patient to choose the option they think is best but the provider should not insist on the patient making the decision that they feel is best (Walker, 2017).
The right for a patient to refuse any medical treatment is well known within medicine as well as the law (Walker, 2017). In cases where patients have lost the ability but had addressed in an advance directive that they did not want life-saving procedures, courts have ruled that their wishes should be honored. Circumstances where there is no written advance directive and the patient is unable to make a medical decision, courts have laws in place for a proxy to make these decisions (Walker, 2017). Cases where patients have expressed their wishes before being deemed incapable to do so, the proxy should follow the wishes rather than make their own decisions (Walker, 2017). This situation is called ‘substituted judgment’ because the proxies use the patient’s prior wishes about treatment as their own (Walker, 2017).
It is well known that there is no ethical obligation for physicians to provide treatment that is futile (Walker, 2017). Unfortunately, futility in the medical sense can have several meanings. When providers do not clarify the term, it can lead to miscommunication and a misunderstanding the patient’s behalf (Walker, 2017). An example of this would be as follows; While explaining to a patient that cardiopulmonary resuscitation (CPR) would be futile, the patient then interprets the meaning of the term to be that treatment will not have any chance of success. If the patient then agrees that CPR would not be a viable option, the decision will have been based completely on a misunderstanding. It is important for providers to be matter of fact about these matters by using simple language instead masking true meaning behind medical terminology (Walker, 2017).
When life sustaining measures are discontinued, whether it be due to medical futility or patient autonomy, there can be extreme emotions that come with our actions (Walker, 2017). This usually stems from failing to clearly differentiate between causing the patient’s death or allowing the patient to pass away. In an unconscious ventilator patient, the patient is alive until the provider removes the ventilator, and the patient soon passes away (Walker, 2017). The timeframe of the patient’s death to the removal of the ventilator leads some medical professionals to wonder whether they have indeed caused the patient’s death (Walker, 2017). In the case where the patient has never been ventilated, death is neither caused nor brought on by the provider but is instead an end of the patient’s disease process (Walker, 2017). Because of this, many medical providers are more comfortable with not starting life sustaining treatment than with stopping it (Walker, 2017). Another issue is the concern of a ventilator as an optional form of external support (Walker, 2017). While the ventilator does sustain a patient’s life, an individual who wishes to forgo this treatment, has the right to do so (Walker, 2017). Many individuals believe beneficial treatment such as antibiotics only serve to interfere with what they believe should be a natural process (Kassim & Alias, 2016).
The decision to withdraw treatment is one that is an argument among many medical professionals as they believe it violates the ethical principal of non-maleficence (Kassim & Alias, 2016). It has also been argued that it is acceptable to withhold or withdraw treatment and allow the disease process to progress and to allow a natural death for the patient (Kassim & Alias, 2016). Any decision to withhold or withdraw treatment should be based upon the expectation that the patient can no longer benefit from that treatment (Kassim & Alias, 2016).
Withdrawing medical treatment has been seen as acceptable for a very long time as there is a distinct difference between acts that are positive and those done by omission (Kassim & Alias, 2016). Euthanasia is when the physician takes the patient’s life based on the wishes and consent of the patient by means of medication (Walker, 2017). The term euthanasia has been defined in various way but in this paper, euthanasia refers to an act in which a physician intentionally causes a patient’s death using medical means. For example, euthanasia is performed when he or she deliberately injects a lethal amount of potassium chloride into a patient for the sole purpose of terminating that patient’s life (Walker, 2017). Euthanasia is very commonly compared to murder because some see it’s motive as malicious rather than assisting a patient to find peace (Walker, 2017). However, it is still considered a form of homicide and is currently illegal in the United States (Walker, 2017). When euthanasia is performed with the consent and understanding of the patient, it is called voluntary euthanasia (Walker, 2017). When euthanasia is performed without a patient’s consent, as with incapacitated patients, it is called non-voluntary or nonchoice euthanasia (Walker, 2017). Assisted suicide is considered voluntary euthanasia that is legal in the state of Oregon (Walker, 2017). In Oregon, a patient can be prescribed a lethal amount of medication so that the patient can take their own life with the medication if he or she so chooses to do so (Walker, 2017). It is considered a form of voluntary euthanasia because the physician consents to assist in a plan to cause the patient’s death and prescribes the lethal dose medication that is used to induce death (Walker, 2017). In voluntary euthanasia, the physician acts independently to end the patient’s life, whereas in physician assisted suicide, the patient and the physician together cause the patient’s death (Walker,2017).
There tends to be a lot of interest in physician assisted suicide among the population (Walker, 2017). This may suggest that the public is not aware of the advances in palliative medicine (Brighton & Bristowe, 2016). Many members of our society wish to have physician assisted suicide and euthanasia as possible options that would be included as benefits of palliative care (Brighton & Bristowe, 2016). The main argument for this issue is of course based on autonomy, but it is an argument that is based on whether it is ethical for a physician to play an active role in causing a patient’s death (Brighton & Bristowe, 2016). In euthanasia and physician assisted suicide, the main ethical issue is it being seen as right or wrong of a physician to cause the death of a patient (Brighton & Bristowe, 2016). The principles of medical ethics are commonly called ‘beneficence’ and ‘nonmaleficence.’ Beneficence means that providers should aim to ‘benefit the ill,’ and nonmaleficence means to ‘do no harm’ while treating the patient (Kassim & Alias, 2016). These principles are the main goal in treating the ill by returning them to health and helping to lessen their suffering (Kassim & Alias, 2016). Ethical issues that involve end of life dilemmas will always be among us as healthcare professionals. We will face situations, that despite our best efforts will not go the way we had planned. Our hearts will break when we overhear the physician tell the patient that nothing more can be done or when a family member makes a decision for our patient that we do not agree with. There will be times that we will see patients give up and others where we will see our patients fight with all that they have. The hardest part that we will face is knowing that sometimes no matter how great the medical effort, not every life can or will be saved.
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