APPLIED ETHICS, EUTHANASIA

EUTHANASIA

            Euthanasia comes from two Greek words, ‘eu’ and ‘thanatos’ which means good death. It is the intentional causing or hastening of death in a person with a medical condition that is judged to be serious. Webster’s New Collegiate Dictionary defines euthanasia as the act or practice of killing individuals…who are hopelessly sick or injured; for reasons of mercy. But this definition limits euthanasia to deliberate killing. The Catholic Church defines euthanasia as an act or omission which, of itself or by intention, causes death in order to eliminate suffering. Euthanasia is also called mercy killing because the prognosis of an illness is shown to be poor and the patient is terminally ill with no hope of recovery.

            In Euthanasia, the patient may be alert, aware and competent to make their own decisions, or may have decreased alertness (due to encephalopathy or coma), diminished awareness (retardation, dementia, vegetative state) and is therefore incompetent to make their own decisions, and unable to communicate due to aphasia or inability to speak.

VOLUNTARY AND INVOLUNTARY EUTHANASIA

            Euthanasia could be voluntary when an alert, aware and competent patient agrees to it being performed. Euthanasia could be involuntary when it is performed on a patient without the patient’s clear understanding and agreement.

            Euthanasia may be considered immoral but not medically unethical. The Catholic Church is completely against Euthanasia (whether voluntary or involuntary) but maintains that a patient who precipitates into the extra-ordinary means of preserving life (ventilator, nutrition and hydration, Narcotics), with the life support machine and constituting an unhealthy financial burden to the family, the person can be allowed to die (letting die) insofar as the person remains in persistent vegetative state (irreversible coma).

KILLING AND LETTING DIE

            The technical expression of killing and letting die is built on the two types of euthanasia. These types of euthanasia make expedient the distinction between killing and letting die.

The two types of euthanasia are:

Active, Direct and Voluntary Euthanasia (also called conscious euthanasia)

            This involves the direct lethal injection of a painless lethal drug and excessive dosage of pain relieving morphine to end the life of a patient. This is direct killing.

Passive, Indirect and Involuntary Euthanasia (also called unconscious euthanasia)

            This involves the indirect withdrawal of all life supporting therapy or hydration and nutrition. This is letting die, that is, letting the patient die.

This explains the technical expressions of killing and letting die in euthanasia.

ASSISTED SUICIDE

            This is when a physician assists a person to commit suicide by providing them with the means to kill themselves. This may include prescribing a lethal dose of oral medications for a patient which the patient then takes at a later time.

Alternatively, the physician may play a more active role by providing a person with a machine that once set in action, automatically delivers a large intravenous dose of a sedative, such as barbiturate, followed by a drug such as a large dose of potassium that stops the heart.

Suicide may also be termed assisted if the ordinary means of preserving life (nutrition & hydration, medication) is withdrawn from the patient at the patient’s request.

WITHDRAWAL OF NUTRITION OR HYDRATION

            This is the discontinuation of food or water by the physician to the patient. This form of euthanasia is increasingly practiced and is often targeted at patients who are in coma and are unable to swallow, or patients with advanced dementia who cannot feed themselves. These patients then, have to be temporarily fed by a feeding tube through the nose or permanently fed by a tube inserted into the stomach through the skin.

            Most patients in whom withdrawal of food and water is considered are not competent to be involved in the immediate decision to discontinue food or water, but, may have made an advance directive that they do not want life support measures taken if they become terminally ill.

PERSISTENT VEGETATIVE STATE (IRREVERSIBLE COMA)

            This is a permanent condition where one typically suffers a severe head injury, prolonged cardiac arrest or multiple strokes, which results to severe brain damage and causes the patient to have reduced awareness and an inability to respond meaningfully to the environment, though may look awake. The patient may be able to breathe on their own or may need ventilator. The patient is usually unable to swallow and needs a feeding tube. Once a persistent vegetative state is established, it is usually permanent.

VENTILATOR-DEPENDENT PATIENT

            A ventilator-dependent patient is a patient who cannot breathe on his or her own. The ventilator is plugged to his or her nostrils to keep the patient alive, enable him or her breathe or reduce the stress encountered in breathing. This is called intubation as the patient is tied to a life support. Once this ventilator is unplugged, the person may die or encounter further severe medical condition. This is clearly a form of euthanasia since the action of switching off the ventilator is a deliberate one, and directly results in the death of the patient.

            The cost of maintenance of this ventilator is quite expensive and this puts the family on the pressure of switching it off if the patient is unable to breathe without it after a trial of several days in the ventilator. Patients with acute reversible respiratory or brain conditions may likely benefit from the ventilator, while patients with longstanding or with severe irreversible brain or lung disease are however unlikely to benefit from a ventilator.

Although the severe brain damage or lung disease is not cured by the machine, the patient may be kept alive by being on the machine, but not be able to breathe sufficiently by themselves to be taken off the ventilator. This is called ventilator-dependent patient.

DO-NOT-RESUSCITATE ORDER (DNR)

            Do-not-resuscitate order is an order placed in a patient’s hospital chart telling the doctor not to attempt to resuscitate a patient if the patient is in imminent danger of death. When signing the DNR (either by the patient or surrogate), the concern is about the ventilator, wherein it has been decided that resuscitation would cause the patient unnecessary suffering and would not alleviate the underlying illness. However, the institution of a DNR order should not be a pretext for reducing the level of nursing and medical care a patient gets.

ADVANCE DIRECTIVE

            An advance directive is a legal document drawn up by a person stipulating their preferences with regard to end-of-life care should they become sick and unable to express these preferences themselves. The advance directive usually states that if the person has a terminal illness that they do not wish extraordinary resuscitative measures to be taken. The problem with this measure is that a severe disabling stroke may be interpreted as a fatal illness. And in this way, it provides a wide range of interpretations for the surrogate, like, refusal to give food and water to a patient with severe but non-fatal medical condition.

PALLIATIVE CARE

            Palliative care refers to the treatment of a patient with a terminal condition, such as cancer, with a therapy that will not cure the patient but will make what remains of their life easier. Here, the patient is no longer administered curable drugs, because his or her condition has been considered medically incurable because of poor prognosis, but is given pain relieving drugs. Palliative care is very important in the management of any incurable illness particularly if the patient is distressed or in pain.

HOSPICE

            This is a center for palliative care. It is a home where patients receiving palliative care live. It is a nursing home where the patient is sent after medical expertise has certified him/her terminally ill. Once sent to a hospice, the patient can no longer return to a hospital but lives on palliative care, and is administered pain relieving drugs like morphine and other sedatives.