physician assisted sucide Essays - Medical Ethics, Euthanasia

Ethical Issues in End-of-Life Care Robert M. Walker, MD The issues associated with appropriate end-of-life interventions involve ethical, moral, and legal decisions by patients and their physicians. Background: Physicians who treat patients approaching the end of life often face moral, ethical, and legal issues involving shared decision making, futility, the right to refuse medical treatment, euthanasia, and physician-assisted suicide. Methods: The author examines cases that involve these issues and also reviews the ethical principles that guide current medical practice. Issues such as end-of-life ethical questions, the right to life-sustaining therapy, medical futility, the distinction between killing and allowing to die, and physician-assisted suicide are discussed. Results: The principal problem involves the appropriate use of technology at the end of life. While developments in technology have enhanced our ability to prolong life, issues have also arisen regarding the resulting quality of life, the sometimes marginal benefits to our patients, and the burdens that this technology imposes on patients, families, and society. Conclusions: Legal and ethical issues continue to confront patients, courts, and physicians. A better understanding of these issues and an awareness of the availability of effective palliative care will help physicians, patients, and families adequately address the end-of-life issues that are an intrinsic part of medical care. Introduction Medicine?s technical advances of the past few decades have cast a shadow over its long-held ethic of compassionate care. The main problem has been the appropriate use of technology at the end of life. Should it be used on everyone, regardless of the chance of successful outcome or the burdens it imposes? If not, what ethical parameters guide the use and non-use of medical interventions? These questions are most sharp at the end of life because the burdens of intervention are often high, the benefits are marginal, and quality of life is markedly diminished. This article reviews the ethical principles that guide medical practice and then focuses on end-of-life ethical issues such as the right to life-sustaining therapy, medical futility, the distinction between killing and allowing to die, and physician-assisted suicide. Ethical Principles The core principles of medical ethics date from antiquity and are commonly labeled "beneficence" and "nonmaleficence." The principle of beneficence holds that physicians should aim to "benefit the sick," while nonmaleficence means to "do no harm" in the process. These principles are reflected in medicine?s chief goal, which is to help the sick by returning them to health and lessening the suffering and decline that is often associated with their diseases.1 The central question in the care of the dying is the appropriate use of life-sustaining interventions. In some cases, there is little or no benefit to be gained by these interventions, and yet the potential for significant harm commonly remains. Ordinarily, when the benefits are clearly outweighed by the potential harms of intervention, the use of that intervention is properly regarded as inappropriate. But who has the ultimate authority to decide the matter of appropriateness? Should it be the physician alone? Should inappropriate ness be decided at the policy level? From an ethics point of view, the patient is the one to decide about forgoing life-sustaining interventions, based on the third ethical principle ? patient autonomy. The principle of autonomy, or respect for persons, has its roots in analytic philosophy and has become synonymous with the concept of self-determination.2 This concept was expressed well by Justice Cardozo in a famous medical malpractice case: "Every human being of adult years and sound mind has a right to determine what shall be done with his own body."3 The principle of autonomy lies at the root of the medical and legal doctrine of informed consent and also at the root of decisions by patients to forgo life-sustaining treatment at the end of life. The fourth ethical principle is that of distributive justice, which guides the fair allocation of medical resources. Justice considerations arise in end-of-life care when one compares the high cost of marginally beneficial end-of-life care to the lack of funding for the basic care of a large portion of our country?s residents. While the issues surrounding medical costs and the design of just health care systems are complex and important, they require a social policy level approach and should not be left simply to the physician at the bedside. The principle of