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Ethical Issues - End of life decisions

Ethical Considerations

A number of ethical theories and principles are relevant when considering treatment decisions at the end of life.

Sanctity of Life Doctrine

The argument underpinning this doctrine is that all human life has worth and therefore it is wrong to take steps to end a person’s life, directly or indirectly, no matter what the quality of that life. This is in keeping with both traditional codes of medical ethics and a general perception of what doctors and other health professionals should do, that is save and preserve life. One challenge to this principle in the context of health care is to ask should life be preserved at all costs. Is there no place for consideration of quality of life? One of the problems with considering quality of life is the question of how this is defined and by whom. An objective view of someone’s life may be very different to the view of the person who is living that life. However, this problem does not remove the challenge to the sanctity of life doctrine. There may be some circumstances where a person’s quality of life, however defined, is so poor that it should not be maintained even if it is possible to do so. Some ethical arguments have been developed to address this challenge.

Acts /omissions distinction

This distinction argues that there is a difference between actively killing someone and refraining from an action that may save or preserve that person’s life. Thus it is morally wrong to push someone into a river to their death but we may not have a moral duty to leap into the river to save someone who is drowning. In a medical context this distinction would mean that a doctor could not give a patient a lethal injection to end his/her life, whatever the circumstances, but could, withhold treatment that may sustain it. Withholding treatment would only be permissible if the patient’s quality of life was so poor, and the burden of treatment so great, that it would not to be in the patient’s best interests to continue treatment. For example, it might be permissible not to ventilate a patient if he/she was in chronic respiratory failure, or not to use tube feeding if he/she was in a permanent vegetative state.

Doctrine of Double Effect

The doctrine of double effect argues that there is a moral distinction between acting with the intention to bring about a person’s death and performing an act where death is a foreseen but unintended consequence.

The doctrine of double effect allows that performing an act that brings about a good consequence may be morally right even though the good consequence can only be achieved at the risk of a harmful side effect. Prescribing pain relieving drugs which in large doses shorten the life of a terminally ill patient is often used as an example of double effect. The intention is to relieve pain and the foreseen but unintended consequence is that the patient’s life will be shortened. Current practice in palliative medicine and the range of drugs available may reduce the appropriateness of this doctrine.

Respect for autonomy

The principle for respect for autonomy acknowledges the right of a patient to have control over his or her own life, including decisions about how his/her life should end. Thus a competent person should be able to refuse life saving treatment in both current situations and future foreseeable situations. Should respect for autonomy mean that a person can request assistance in ending his/her life? Some would argue that this is the case but as assisted suicide is currently illegal in the UK this is not an issue that a clinical ethics committee should need to consider. Does respect for autonomy mean that a patient can request treatment that the clinician does not think is in his/her best interests, or treatment that is futile? In these situations the principle of respect for autonomy comes into conflict with other ethical considerations, such as preventing or avoiding harm, or distributive justice.

A duty to act in the patient’s best interest (Beneficence)

The duty of beneficence, that is to act in a way that benefits the patient, is an important ethical principle in health care. In treatment decisions at the end of life the dilemma often revolves around what course of action will be in the patient’s best interests. It is difficult to see how death can be a benefit or in the patient’s interests, but in some circumstances, if existing quality of life is so poor, or treatment is very burdensome, then the balance of harms and benefits may suggest that continuing treatment is not a benefit to the patient.

A duty not to harm (Nonmaleficence)

The concept of nonmaleficence - an obligation not to inflict harm intentionally, is distinct from that of beneficence - an obligation to help others. In codes of medical practice the principle of nonmaleficence (primum non nocere) has been a fundamental tenet. However, in the context of health care it can sometimes be difficult to comply with this principle depending on the definition of harm. Many medical treatments may have harmful side effects but save or improve lives. In end of life decisions the question of how much harm is caused by the treatment needs to be considered, as does the question of whether death itself is always a harm.