Bioethical Issues

in End of Life
Abd. Razak Datu

End-of-life
End of life issues range from
attempts to prolong the lives of
dying patients through highly
experimental technologies, such as
To effort to terminate life
prematurely through euthanasia
Medically assisted suicide

 The care of patients near the end of

life can be ethically challenging.
Physicians may find certain concepts
vague and hard to understand.
Furthermore, there must be a balance
between two extremes: a treat-at-allcosts vitalism on the one hand, and a
too-rapid withdrawal of potentially
beneficial treatments on the other.

 A terminal condition is a disease or disease

process that will result eventually in a
patients death, no matter what treatment is
given.
Of course, this may include cases where death
is inevitable but far off, as in patients with
cancer who live for years with their disease.
On the other hand, the expression imminent
death is used when death is expected within a
short time, usually days or weeks.

End-of-life

Two issues deserve particular attention:

Euthanasia,
and
Assistance in Suicide

EUTHANASIA
The word euthanasia comes from two
Greek words: eu for good, and
thanatos for death. Thus the term
means a good or gentle death.
Euthanasia often has a positive
conotation in the idea that a
suffering person will be relieved by
means of a mercy killing.

EUTHANASIA
Euthanasia means knowingly and
intentionally performing an act that is
clearly intended to end another persons
life and that includes the following
elements :
the subject is a competent, informed person
with an incurable illness who has
voluntarily asked for his or her life to be
ended;
the agent.....

EUTHANASIA
the agent knows about the persons
condition and desire to die, and
commits the act with the primary
intention of ending the life of that
person;
the act is undertaken with
compassion and without personal
gain

ACATIVE AND PASSIVE

EUTHANASIA

Active euthanasia is the overt, deliberate

killing of a patient, e.g., by injecting an
overdose of morphine or by giving
potassium chloride to stop the heart.
Passive euthanasia refers to the
withdrawing or withholding of treatment,
while the disease process takes its course
to cause death. In other words, the
distinction is between killing and letting
die, but the intent in both is the patients
death.

ACTIVE EUTHANASIA
Most would condemn active killing.
Letting die may seem to be more
acceptable, though it can be just as
unethical as active killing. Some
ethicists would thereby argue that
there is no morally relevant
distinction between active and
passive euthanasia.

PASSIVE EUTHANASIA
However, this oversimplifies the reality of
medical care.
Letting die may be morally justifiable in
medicine if a particular intervention is truly
futile, or if a patient or her authorized
surrogate refuses it.
Thus, the medical cause of death does
have moral relevance, though not in and of
itself. For these reasons, the term passive
euthanasia has only added confusion to the
ethical debate, and should be discarded.

VOLUNTARY,
NONVOLUNTARY,AND
INVOLUNTARY EUTHANASIA

Another way to look at euthanasia

involves three categories:

voluntary, nonvoluntary, and

involuntary.
Voluntary euthanasia is the act
of bringing about a competent
patients death at his request.

 Nonvoluntary euthanasia means

ending the life of an incompetent
patient, usually at the request of
a family member
Involuntary euthanasia means
taking the life of a competent
patient who does not wish to die.

 As Voluntary euthanasia, the active

taking of a patients life is usually
considered wrong, even if a patient
requests it. The focus here is on the
agent who gives consent, rather than
on the ethical merits of the act of
killing or letting die.

ASSISTANCE IN SUICIDE
Physician-assisted suicide is a
variation of voluntary active
euthanasia, where the agent who
causes the death is the patient
herself, with means provided by the
physician.

ASSISTANCE IN SUICIDE
Assistance in suicide means
knowingly and intentionally
providing a person with the
knowledge or means or both
required to commit suicide, including
counselling about lethal doses of
drugs, prescribing such lethal doses
or supplying the drugs.

 Euthanasia and assisted suicide are often

regarded as morally equivalent, although
there is a clear practical distinction, and in
some jurisdictions a legal distinction,
between them.
Euthanasia and assisted suicide, are to be
distinguished from the withholding or
withdrawal of inappropriate, futile or
unwanted medical treatment or the
provision of compassionate palliative care,
even when these practices shorten life.

 Requests for euthanasia or

assistance in suicide arise as a result
of pain or suffering that is considered
by the patient to be intolerable.
They would rather die than continue
to live in such circumstances.

 Furthermore, many patients consider

that they have a right to die if they so
choose, and even a right to assistance
in dying.
Physicians are regarded as the most
appropriate instruments of death since
they have the medical knowledge and
access to the appropriate drugs for
ensuring a quick and painless death.

 Physicians are understandably

reluctant to implement requests for
euthanasia or assistance in suicide
because these acts are illegal in
most countries and are prohibited in
most medical codes of ethics.

Declaration on
Euthanasia:
Euthanasia, that is the act of deliberately
ending the life of a patient, even at the
patients own request or at the request
of close relatives, is unethical.
This does not prevent the physician from
respecting the desire of a patient to
allow the natural process of death to
follow its course in the terminal phase of
sickness.

 The rejection of euthanasia and

assisted suicide does not mean that
physicians can do nothing for the
patient with a life-threatening illness
that is at an advanced stage and for
which curative measures are not
appropriate.

 In recent years there have been

great advances in palliative care
treatments for relieving pain and
suffering and improving quality of
life. Palliative care can be
appropriate for patients of all ages,
from a child with cancer to a senior
nearing the end of life.

 All physicians who care for dying patients

should ensure that they have adequate
skills in this domain, as well as, where
available, access to skilled consultative
help from palliative care specialists.
Physicians should not abandon dying
patients but should continue to provide
compassionate care even when cure is no
longer possible.

Declaration of Geneve:
I will maintain the utmost respect for
human life from its beginning even
under threat and I will not use my
medical knowledge contrary to
humanity.

 The approach of death presents many

other ethical challenges for patients,
substitute decision-makers and
physicians.
The possibility of prolonging life through
recourse to drugs, resuscitative
interventions, radiological procedures and
intensive care requires decisions about
when to initiate these treatments and
when to withdraw them if they are not
working.

 in relation to communication and consent,

competent patients have the right to
refuse any medical treatment, even if the
refusal results in their death.
Individuals differ greatly with regard to
their attitude towards dying; some will do
anything to prolong their lives, no matter
how much pain and suffering it involves,
while others so look forward to dying
that they refuse even simple measures
that are likely to keep them alive, such as
antibiotics for bacterial pneumonia.

 Once physicians have made every

effort to provide patients with
information about the available
treatments and their likelihood of
success, they must respect the
patients decisions about the
initiation or continuation of any
treatment.

 End-of-life decision-making for

incompetent patients presents greater
difficulties. If patients have clearly
expressed their wishes in advance, for
example in an advance directive, the
decision will be easier, although such
directives are often very vague and
need to be interpreted with respect to
the patients actual condition.

 If patients have not adequately

expressed their wishes, the
appropriate substitute decisionmaker must use another criterion for
treatment decisions, namely, the
best interests of the patient.