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PHI 204 - Medical Decisions at the End of Life


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PHI 204 - Medical Decisions at the End of Life

  1. 1. Medical Decisions at the End of Life (Biomedical Ethics) Charles Lohman
  2. 2. Defining Death <ul><li>Until the second half of the twentieth century, DEATH was when a person stopped breathing and their heart stopped beating. </li></ul><ul><ul><li>BUT the definition of DEATH shifted focus from the lungs and heart to the BRAIN with the introduction of the mechanical ventilator in the late 1960s and early 1970s. </li></ul></ul><ul><ul><ul><li>The mechanical ventilator made it possible for a person’s lungs and heart to function when they could no longer. </li></ul></ul></ul>
  3. 3. Whole Brain Criterion of Death <ul><li>The whole brain criterion of DEATH has been widely accepted by the general public and adopted in legal and clinical practice. </li></ul><ul><ul><li>The whole brain criterion of DEATH is when all BRAIN functions, including those of the cerebral cortex and brain stem, have permanently ceased. </li></ul></ul><ul><ul><ul><li>Why? </li></ul></ul></ul><ul><ul><ul><ul><li>BECAUSE these functions are necessary for the integrated functioning of the organism as a whole. </li></ul></ul></ul></ul>
  4. 4. Whole Brain Criterion of Death 1 of 2 Challenges <ul><li>1.) The whole BRAIN criterion suggests that the BRAIN controls and integrates all bodily processes. </li></ul><ul><ul><ul><li>BUT the whole BRAIN criterion is physiologically inaccurate. </li></ul></ul></ul><ul><ul><ul><ul><li>The BRAIN does not control nor integrate all bodily processes. </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>FOR EXAMPLE, although the BRAIN mediates breathing and nutrition, these bodily functions are not reducible to or completely controlled by the activity of the BRAIN. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Some of the body’s integrated functions can continue for some time after the BRAIN has ceased to function. </li></ul></ul></ul></ul></ul>
  5. 5. Whole Brain Criterion of Death 2 of 2 Challenges <ul><li>2.)DEATH should be when the higher BRAIN necessary for CONSCIOUSNESS permanently ceases to function. </li></ul><ul><ul><ul><li>DEATH should not be defined in terms of the whole BRAIN. </li></ul></ul></ul><ul><ul><ul><ul><li>But should be defined in terms of the capacity for CONSCIOUSNESS. </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>CONSCIOUSNESS depends on the activity of the cerebral cortex so the permanent cessation of cortical function is sufficient for the DEATH of a person. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>So based on this definition a person may be DEAD although he/she is still breathing and his/her heart is still beating. </li></ul></ul></ul></ul></ul>
  6. 6. WITHDRAWING and WITHHOLDING Treatment <ul><li>Both WITHDRAWING and WITHHOLDING life-sustaining treatment can lead to a patient’s DEATH. </li></ul><ul><ul><li>So there does NOT ‘seem’ to be a MORALLY significant difference between the WITHDRAWING and WITHHOLDING treatment. </li></ul></ul><ul><ul><ul><ul><li>In other words, if one FORESEES that their actions or ‘non-action’ will ensure an OUTCOME, then one plays a causal role in the outcome by intentionally acting or by intentionally omitting to act. </li></ul></ul></ul></ul>
  7. 7. It’s about the Patient’s Best Interest <ul><li>How ACTION and OMISSION benefit or harm the patient is what is MORALLY relevant. </li></ul><ul><ul><li>What is NOT MORALLY relevant is WITHDRAWING and WITHHOLDING treatment. </li></ul></ul><ul><ul><ul><li>In other words, it’s about the patient’s best interest. </li></ul></ul></ul><ul><ul><ul><ul><li>For example, a doctor may be obligated to withdraw a treatment if it is clear that it offers no benefit to and only harms the patient. </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>If a treatment is not likely to reverse a condition, then there is no duty to initiate it. Similarly, if an initiated treatment cannot reverse a condition, then there is no duty to continue it. </li></ul></ul></ul></ul></ul>
  8. 8. Double Effect <ul><li>Double Effect (DDE) specifies a moral distinction between INTENDING a harmful effect by acting, and FORESEEING a harmful effect as an unintended outcome of a good action. </li></ul><ul><ul><li>In DDE, the distinction is between DIRECT AND INDIRECT agency. </li></ul></ul><ul><ul><ul><li>In other words, the distinction is between ‘what we do’ and ‘what we bring about’ as a result of what we do. </li></ul></ul></ul>
  9. 9. Double Effect’s Morality <ul><li>With DDE, it is MORALLY permissible to give a high dose of morphine to relieve a patient’s pain when a doctor FORESEES that it will hasten the patient’s death. BUT it is MORALLY impermissible to give morphine in order to bring about the patient’s death. </li></ul><ul><ul><li>In other words, the doctor can NOT permissibly kill the patient as an intended means to the end of relieving pain. </li></ul></ul><ul><ul><ul><li>So, in short, with DDE, the death is a side effect of giving the morphine. </li></ul></ul></ul><ul><ul><ul><ul><li>Whereas it is not the doctors goal or reason for giving it so it is not intended to kill the patient. </li></ul></ul></ul></ul>
  10. 10. Euthanasia Physician-Assisted Suicide <ul><li>EUTHANASIA – death that benefits the person who dies. </li></ul><ul><li>PHYSICIAN-ASSISTED SUICIDE (PAS) – the act that results in the death is performed by the patient, who is assisted by a physician or someone else who provides the means through which the patient can take his/her own life. </li></ul>
  11. 11. The 3 Types of EUTHANASIA <ul><li>Voluntary EUTHANASIA – involves a patient making a voluntary and persistent request that someone actively cause his/her death. </li></ul><ul><li>Involuntary EUTHANASIA – involves killing a patient against his/her expressed wishes to the contrary, or without consulting such wishes. </li></ul><ul><li>Nonvoluntary EUTHANASIA – involves someone killing a patient who is incompetent and unable to express his/her wishes about wanting to live or die. </li></ul>
  12. 12. PAS’s 6 Conditions <ul><li>PAS’s 6 conditions to be morally permissible: </li></ul><ul><ul><li>1.) There must be a diagnosis of terminal illness. </li></ul></ul><ul><ul><li>2.) The patient must be suffering from an unbearable and irreversible condition. </li></ul></ul><ul><ul><li>3.) The patient must be informed about the diagnosis and prognosis of his/her condition, as well as about alternatives to PAS, such as hospice care and other palliative services. </li></ul></ul><ul><ul><li>4.) The patient who requests PAS must not be suffering from treatable depression. </li></ul></ul><ul><ul><li>5.) The patient must make an enduring and voluntary request for assistance in dying. </li></ul></ul><ul><ul><li>6.) When a patient dies as a result of PAS, the doctors who assist him/her must report it to the regulatory authorities. </li></ul></ul>