The case of Terri Schiavo, the 41-year-old brain-damaged woman, who was kept alive in a vegetative state for 15 years despite her husband’s fervent pleas to allow her to die without causing further pain or agony, is viewed as an important case in ethics in healthcare. The objection to “allow her to die” had come from her parents. After a prolonged and bitter court hearings, the end came following the court’s order to disconnect Schiavo from life supporting feeding tubes was carried out on March 18, 2005, She died of dehydration 13 days later on March 31. Take another ethical case of “Quinlan a comatose young woman in a vegetative state with no hope of recovery and for which her family fought over the right to have her die without continuing artificial life support, courts and legislation have outlined the legal bounds governing medical conduct vis-à-vis the dying process”, Cantor 2001 183).
The existence of cases cited above have necessitated a re-look at the question of clinical ethics where a right-to-dignified death is involved. It’s also the time to evaluate how the medical professionals are treading a thin line ethically in dealing with the terminally ill patients, their needs and right to freedom of a death with dignity.
Consider the dilemma of a doctor when confronted with removing feeder tubes, inflicting dehydration, or withdrawing life-support systems from a dying patient, vis-à-vis the ‘Hippocratic Oath’ sworn by all passing-out medical graduates, which embodies them that at the very least, doctors will do no harm. “…I will remember that I remain a member of society, with typical obligations to all my fellow human beings, those sound of mind and body as well as the infirm…” the oath continues.
Medical ethics confronts many issues; you could say it has a multi-pronged approach. Whether you are taking care of a family member or a community affected by natural disaster, these medical ethics questions are important to know.
First, your doctor will look at the aspect of health that is known as ‘patient’s autonomy’. Under the ethical question of ‘autonomy’, the issue at hand is the right of the person to make a decision for himself. The healthcare professional will consider the requests of the patient before those of the family members. This is considered the autonomy of the patient.
The next factor the healthcare team will address is what is known as ‘distributive justice’. The physician will assess the fairness of the treatment to ensure it is fairly distributed. In other words, when caring for a patient who requires a transplant, the aspect of ‘justice’ is applied and transplant is provided to those on a transplant list in terms of what is deemed fair by hierarchy of need.
‘Nonmaleficence’ is the third aspect of medical ethics that deals with the care and how it may affect or harm others. When considering the health of an individual, the physician must look at the impact of treatment or care upon the ramifications such treatment may have on the family and community. Often, if the treatment is not life threatening to the community, it is considered nonmaleficence. In terms of public health, the application of specific care must not be a threat to the general public for the sake of benefiting a few.
And, finally, there is a question of ‘beneficence’. It obligates doctors morally to advise their patients/families about their health; that is, to act for the good of their patients.
What this implies, in many cases of terminally ill patients, is that the doctor becomes ‘paternal’- that is, he has to make decisions for the patient, sometimes with or without family’s knowledge or approval.
“The right of the patient to direct his medical care and health outcome, known as patient autonomy, and the right of society to control and allocate ‘limited resources’, known as ‘distributive justice’, will certainly collide” (Guellec 1999 1). Guellec adds further that the ethical and moral beliefs of society- especially of the medical profession- has changed and is continuing to change. “According to Hiller (1986), six ethical principles are relevant for medical professionals. They are beneficence, non-malfeasance, respect for persons, justice, utility, and truth telling” (Guellec 1999 1). But, as she points out, this perhaps not the way the patients or their families see the need to keep a dying person alive or to withhold some medication or nutrition to allow a death with dignity.
Beneficence is the principal governor of the medical ethics with respect to doctors. It obligates them morally to advise their patients/families about their health; that is, to act for the good of their patients. What this implies, in many cases of terminally ill patients, is that the doctor becomes ‘paternal’- that is, he has to make decisions for the patient, sometimes with or without family’s knowledge or approval.
There are times when the question of death with dignity crosses ethical lines. There are many cases where terminally ill patients request to be given a last opportunity not to die in pain and agony. In some cases, doctors have perhaps given a strong sedative, which induces a coma and eventual death without the patient’s feeling anything. But, when a dying patient slips in and out of consciousness, what choice do doctors have for some sort of informed consent to stop nutrition, water, or other life-giving stimulants. “Should they wake her up, or should they make treatment decisions on her behalf?” (Elger & Chevrolet 2000 18).
To the issue of whether doctors should tell the truth to their patients, the AMA’s Principles of Medical Ethics state, “A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights (AMA). This effectively states that doctors, indeed, shall tell the truth. However, in the advancing filed of medical ethics, what assumes importance is the timing of telling the truth, how to best tell the truth, how much truth to tell, and who decides these issues and many more. Is withholding any part of the truth a lie? What if the patient could be harmed by the information? Should the doctor still tell the truth? What if the patient is too ill to understand the information? Does the doctor still tell the patient? Who else does he tell? Who makes the decision about treatment? How are these issues decided and many more? If doctors tell the truth in certain situations, they may actually harm their patients. However, if they do not tell the truth, the patient’s trust in the doctor and the entire medical profession can be eroded. There are two schools of camp-one that believes doctors are acting within the best limits of their profession and one who feels that doctors are making too many decision for patients.
If I were to decide issues personally, I would always favor the truth. However, as
Dr. James F. Drane says: “To tell the truth in the clinical context requires compassion, intelligence, sensitivity, and a commitment to stay with the patient after the truth has been revealed” (Drane). The demands for doctors are becoming more and more, but they really should not be doctors if they cannot commit to the above quote. However, the problem of how much truth to tell and when to tell it comes into play. If a patient is clinically depressed and/or suicidal, should a doctor fully disclose something catastrophic?
However, many people prefer a more compassionate approach than brutal full disclosure. “Telling the truth in a clinical context is an ethical obligation but determining just what constitutes the truth remains a clinical judgment” (Drane)
From the point of view of health professionals, the ethical and moral dilemmas they often face are moving away from the traditional concept of always saving a life. “The prohibition of killing, it is said, does not entail that the physician must always preserve a life. While physicians must not intentionally cut short a patient’s life, or engage in acts of euthanasia, they may sometimes, under the principle of double effect- act in ways that will foreseeably but non-intentionally cause death” (Kuhse 2002 271).
Suppose one patient asks to die, what should the doctor do? The ethics committee of the British Medical Association recently published guidelines on decision making…”Although patients’ wishes should always be discussed with them, the fact that a patient has requested a particular treatment does not mean it must always be provided…. A life-prolonging treatment may, for example, prolong life but result in severe pain or loss of function so that overall it produces severe harm to the patient” (Williams 2000 85).
Again, what if a terminally ill patient’s family member requests that tube feeding be stopped? In a particular case cited in Family and Community Health (Jan. 1999), the medical facility refused and the case went to court. Eventually, “the state Supreme Court ruled that removal of tube feeding was legally permissible when the patient had no chance for recovery, and the mother did indeed have the right to make this decision” (Seibold 1999 83).
The UK now has a ruling on withholding nutrition: “In NHS Trust v. Bland (1993)…. the House of Lords held it lawful for a doctor to withhold tube-delivered food and fluids
from his patient in a persistent vegetative state…even though this would cause death by dehydration. The most controversial aspect of the case was the further ruling by three of their Lordships that it was lawful even though the doctor’s purpose was not merely to withdraw what he regarded as ‘futile medical treatment’ but was precisely to kill the patient” (Keown 2001 53).
This case, and others with similar results, show that these “cases have shifted the balance of power in decision making away from doctors and toward patients and their families” (Stein 1999 12). It would seem only rational to put aside the ethical question, when the court has decided that a patient with no chance of survival, or, in some instances, a comatose patient with no brain function who has no chance of returning to consciousness, can be deprived of nutrition with the consent of a family member. In a way, this is a big relief for the doctors who have to make a fateful decision. What a terrible dilemma for the doctor if the only competent family member(s) suggest that he make the decision.
An annual survey by Gallup on the topic Values and Beliefs, conducted from May 8-11, 2006, found that the majority of Americans support “right-to-die” laws for terminally ill patients, whether that involves a doctor ending a patient’s life by some painless means, or a doctor assisting a terminally ill patient to commit suicide.
Half of the respondents in the survey were asked this long-term Gallup trend question on euthanasia: “When a person has a disease that cannot be cured, do you think doctors should be allowed by law to end the patient’s life by some painless means if the patient and his family request it?”
The other half of the respondents were asked this question that specifically mentions suicide: “When a person has a disease that cannot be cured and is living in severe pain,
do you think doctors should or should not be allowed by law to assist the patient to commit suicide if the patient requests it?”
Both questions find that more than 6 in 10 Americans support the notion of euthanasia or doctor-assisted suicide.
2003-2006 Aggregate
At times health professionals impart an economics rationale within the moral and ethical framework: “Where resources are limited, it is inevitable that some patients will not receive all of the treatment they request…Health professionals have am ethical duty to make the best use of the available facilities…” (Williams 2000 85). But the realities are different. Many hospitals attempt to move terminally ill patients who linger after their insurance has expired. Some hospitals are even accused of deliberately inducing dehydration and starvation in order to cut costs, and make the room available for other patient.
One must therefore take recourse to all the opinions available – medical, legal, and personal – and come to a considered conclusion about life’s dilemma and then provide a ‘living will’ with a view to directing the doctors when necessary- a document that plainly states, what he wants to be done with his life. Perhaps the time has come to have more medical lawyers offer and prepare such living wills. It would be helpful, near one’s end of life, to know when to remove feeding tubes- after missing one, or two feedings? Or when to remove artificial means that sustains life.
In essence, the real dilemma is: “Does it make much of a difference…whether one causes or merely hastens death?” (Perkin 2002 164)
Works Cited
Cadena, Christine.: Medical ethics and 4 pronged approach to healthcare. 10 Sept 2007
http://www.associatedcontent.com/article/367060/medical_ethics_the_four_prong_approach.html?singlepage=true;cat=5
Carroll, Joseph.: Public Continues to Support Right-to-Die for Terminally Ill Patients. 19 June 2006
http://www.deathwithdignity.org/news/news/gallup.06.19.06.asp
Haas, Warner.: Medical Ethics and the Terminally Ill
http://www.associatedcontent.com/article/125398/medical_ethics_and_the_terminally_ill.html
Moore, Julie.: Medical ethics-should doctors tell their patients the truth. 17 Dec 2007
http://www.associatedcontent.com/article/474855/medical_ethics_should_doctors_tell.html?singlepage=true;cat=5
Terri Schiavo has Died. March 31, 2005. http://www.cnn.com/2005/LAW/03/31/schiavo/index.html
