END-OF-LIFE

BASIC CONCEPTS“THOU OWEST GOD A DEATH”

QUALITY OF LIFEA FORMULA [SHAW, 1986/1994]

• QL = NE X (H + S)• NE --- NATURAL (PERSONAL)

ENDOWMENT• H --- CONTRIBUTIONS OF THE

HOME• S --- CONTRIBUTIONS OF SOCIETY

QUALITY OF LIFEESSENTIAL FEATURES [SPITZER ET AL., 1981]

• ACTIVITY (WORK, PLAY, STUDY) --- INVOLVEMENT IN OCCUPATION

• TASKS OF DAILY LIVING --- ORDINARY LIFE ACTIVITIES

• HEALTH (FEELING OF WELL-BEING) --- PERCEPTION OF ONE’S OWN HEALTH

• SUPPORT FROM FAMILY AND FRIENDS• PSYCHOLOGICAL, SPIRITUAL OUTLOOK

ON LIFE

QUALITY OF LIFEWAYS OF TALKING

• THE SUBJECTIVE SATISFACTION EXPRESSED OR EXPERIENCED BY AN INDIVIDUAL IN HIS/HER PHYSICAL, MENTAL, AND SOCIAL SITUATION

• THE SUBJECTIVE EVALUATION BY AN ONLOOKER OF ANOTHER’S SUBJECTIVE EXPERIENCES OF PERSONAL LIFE

• THE ACHIEVEMENT OF CERTAIN ATTRIBUTES HIGHLY VALUED IN OUR SOCIETY, AS REFLECTED IN A SOCIAL AND CULTURAL BIAS ABOUT THOSE FACTORS WHICH CONTRIBUTE TO A LIFE WORTH LIVING

• A LEVEL OF CAPABILITY AND ACTIVITY WHICH CONTRIBUTES TO THE INDIVIDUAL’S ABILITY TO FLOURISH– FLOURISHING --- THE FULFILLMENT OF THE POTENTIAL AN

INDIVIDUAL MAY POSSESS FOR MEANINGFUL EXISTENCE [BEYOND MERE SURVIVAL]

MEANS FOR EXTENDING LIFE

• ORDINARY (PROPORTIONATE)– ALL MEDICINES, TREATMENTS, AND OPERATIONS, WHICH OFFER

A REASONABLE HOPE OF BENEFIT FOR THE PATIENT AND WHICH CAN BE OBTAINED AND USED WITHOUT EXCESSIVE EXPENSE, PAIN, AND OTHER INCONVENIENCES

• EXTRAORDINARY (DISPROPORTIONATE)– ALL MEDICINES TREATMENTS, AND OPERATIONS, WHICH CANNOT

BE OBTAINED WITHOUT EXCESSIVE EXPENSE, PAIN, OR OTHER INCONVENIENCE, OR WHICH, IF USED, WOULD NOT OFFER A REASONABLE HOPE OF BENEFIT.

• “ONE CANNOT IMPOSE ON ANYONE THE OBLIGATION TO HAVE RECOURSE TO A TECHNIQUE WHICH IS ALREADY IN USE BUT WHICH CARRIES A RISK OR IS BURDENSOME. SUCH A REFUSAL IS NOT THE EQUIVALENT OF SUICIDE [OR HOMOCIDE]; ON THE CONTRARY IT SHOULD BE CONSIDERED AS AN ACCEPTANCE OF THE HUMAN CONDITION.”

BENEFITS

• THE POSITIVE RESULT FOR A FUNCTIONAL IMPROVEMENT IN THE QUALITY OF LIFE OR THE ACHIEVEMENT OF A PARTICULARLY DESIREABLE GOAL WHICH AN INDIVIDUAL WILL EXPERIENCE AS THE RESULT OF A HEALTHCARE INTERVENTION

• COMPLETE RECOVERY• REMISSION OF DISEASE PROCESS• IMPROVED QUALITY OF LIFE

– COMFORT– RESTORATION OF

CONSCIOUSNESS– IMPROVED PERFORMANCE

ACTIVITY• RETURN TO A PREVIOUS LEVEL OF

FUNCTIONING• MAINTENANCE OF A MINIMALLY

DECENT QUALTIY OF LIFE• FIGHTING A DISEASE• EXPERIENCING A LESS DISTRESSING

DYING• COST/RESOURCE SAVINGS• [CONTINUED BIOLOGICAL EXISTENCE]

BURDENS

• THE SUFFERING ONE MUST ENDURE AS THE RESULT OF AN INTERVENTION; IT MAY TAKE A PHYSICAL, PSYCHOLOGICAL, SPIRITUAL, OR MORAL FORM

• TOO PAINFUL• TOO DAMAGING TO

BODILY SELF AND FUNCTIONING

• TOO PSYCHOLOGICALLY REPUGNANT TO THE PATIENT

• TOO RESTRICTIVE OF PATIENT’S LIBERTY AND PREFERRED ACTIVITIES

• TOO SUPPRESSIVE OF PATIENT’S MENTAL LIFE

• TOO EXPENSIVE

WEIGHING BENEFITS AND BURDENS• WHAT IS THE GOAL OF THE INTERVENTION?

– WILL THE GOAL BE ACCOMPLISHED?– RELATION OF GOAL TO PATIENT’S LIFE-STYLE CHOICES

• THE BENEFITS OF THE INTERVENTION?– RELATION OF BENEFITS TO LIFE-STYLE CHOICES– ARE BENEFITS WORTH THE BURDENS?

• THE BURDENS OF THE INTERVENTION?– RELATION OF BURDENS TO LIFE-STYLE CHOICES– ARE BURDENS TOLERABLE?– DO BURDENS MINIMIZE BENEFITS?

• WHO MOST DIRECTLY BEARS THE BURDENS?• WILL THE PATIENT HAVE TO BEAR THE BURDENS ALONE?

ACTIVE - PASSIVE EUTHANASIAOLD STYLE

• ACTIVE– DOING SOMETHING/TAKING THE INITIATIVE

• DIRECT CAUSE IN PRODUCING THE EFFECT OF DEATH– E.G. GIVING A LETHAL INJECTION

• PASSIVE– NOT DOING A SPECIFIC THING/ALLOWING SOMETHING TO

HAPPEN• INDIRECT CAUSE IN PRODUCING THE EFFECT OF

DEATH– E.G. WITHHOLDING OR WITHDRAWING AN

INTERVENTION– ALLOWING THE NATURAL COURSE OF EVENTS TO

FOLLOW

ACTIVE - PASSIVE EUTHANASIANEW STYLE

• ACTIVE– DOING “x” = DOING SOMETHING

• PASSIVE– DOING “NON-X” = DOING SOMETHING

• BOTH INVOLVE TAKING AN INITIATIVE AND PRODUCING THE SAME END– UTILIZE DIFFERENT MEANS

• BOTH INVOLVE A DOING --- MINIMALLY A MENTAL ACTION• MORAL EQUIVALENTS BUT MAY HAVE DIFFERENT

PSYCHOLOGICAL EFFECTS• ACTIVE MAY BE MORE HUMANE THAN PASSIVE SINCE

SUFFERING IS TERMINATED SOONER

PRINCIPLE OF DOUBLE EFFECTACTIONS WITH TWO EFFECTS; ONE GOOD, ONE BAD

• ONE MAY NOT WILL EVIL DIRECTLY• ONE MUST INTEND THE GOOD EFFECT BUT MAY PERMIT

OR TOLERATE THE EVIL EFFECT– E.G. REMOVAL OF VENTILATOR TO PRODUCE

COMFORT– E.G. THERAPEUTIC LEVELS OF PAIN MEDICATION

• GOOD EFFECT MUST NOT COME ABOUT AS A CAUSAL RESULT OF AN EVIL ACTION– E.G. KILLING THE PATIENT TO ACHIEVE PAIN RELIEF

• THERE MUST BE A PROPORTIONATE REASON FOR THE PROCEDURE

VOLUNTARY AND INVOLUNTARY• INVOLUNTARY

– ACTIVE --- CONSTANT MEDICAL PROHIBITION– PASSIVE --- ACCEPTED AS W/W IN

“HOPELESS” CASES (BENEFICENCE)• VOLUNTARY

– ACTIVE --- EQUIVALENT OF SUICIDE: STRONG MORAL PROHIBITION• NO CONSTITUTIONAL PROTECTION• REFUSAL OF TREATMENT, NOT SUICIDE

– PASSIVE --- ACCEPTED AS TREATMENT REFUSALS (AUTONOMY)

WHY ACTIVE EUTHANASIA NOW?ASSISTED SUICIDE AND ALTERNATIVES

• TO AVOID PAIN– PAIN MANAGEMENT– WITHHOLDING/WITHDRAWING TREATMENTS

• T0 AVOID A PROTRACTED DYING PROCESS– SUPPORT PATIENT IN TREATMENT REFUSALS– EXPLORE POSITIVE AVENUES OF PERSONAL GROWTH

• TO AVOID INSTITUTIONS WHERE PATIENT “WILL NOT BE ALLOWED TO DIE”– CREATE ENVIRONMENTS TOLERANT OF A VARIETY OF DEATH-STYLES– UTILIZE WIDE RANGE OF ACCEPTABLE MEDICAL PRACTICES– ASSESS BENEFITS REALISTICALLY– RESPECT PATIENT AUTONOMY

• TO AVOID EXCESSIVE EXPENSES– RESPECT TREATMENT REFUSALS– ASSESS BENEFITS REALISTICALLY– UTILIZE LOW TECHNOLOGY INTERVENTIONS

• TO AVOID HUMILIATION AND INDIGNITY IN DYING– EXPLORE WAYS OF PROMOTING DIGNITY– EXPLORE AVENUES OF HOPE IN A LIMITED CONTEXT

TERMINAL [PALLIATIVE] SEDATIONA FORM OF OR ALTERNATIVE TO EUTHANASIA?

• RIGHT TO CONSENT TO OR REFUSE TREATMENTS [PSDA]

• GOAL OF MEDICINE: RELIEF OF PAIN AND SUFFERING CAUSED BY MALADIES

• TREATMENT TO PROVIDE BENEFITS OR REDUCE BURDENS– PAIN– SUFFERING

• ADEQUATE PAIN CONTROL– HASTEN DEATH– PROLONG LIFE

TERMINAL SEDATION AND DOUBLE EFFECT• TWO EFFECTS --- ONE GOOD, ONE UNDESIRABLE• CANNOT ACHIEVE GOOD BY IMPROPER MEANS• INTEND THE GOOD EFFECT; CANNOT WILL EVIL DIRECTLY• MUST BE PROPORTIONATE REASON

– RELIeVE INTRACTABLE PAIN– PRODUCE UNCONSCIOUSNESS BEFORE TERMINAL WEANING– RELIEVE EXISTENTENTIAL SUFFERING

• INTENTION [DIVIDING INTENTIONS]– RELIEVE PAIN [AND SUFFERING]/NOT CAUSE DEATH– SEDATION = RELIEVE PAIN

• WITHHOLD/WITHDRAW NUTRITION AND HYDRATION =

NONBENEFICIAL