Killing or Letting Die?

The patient who has the capacity to make autonomous decisions themselves may terminate life-supporting treatment. In most cases within hospital intensive care units where many of these decisions are requested, the patient may not have the physical ability to perform the act to discontinue the treatment. This means that physicians or hospital staff must carry out the act. The question then arises as to whether the perhaps lethal consequence of the act represents the act itself or represents the patient’s underlying disease; in essence, does “pulling the plug” by the healthcare professionals represent an act of killing the patient or allowing the patient to die from his or her illness which required the life-support? The current usual view that has been suggested to make the distinction is regarding the intent of the person who performs the act. Is the person simply following the patient’s legal request as an ethical responsibility with perhaps knowing that death is possible due to the patient’s illness but not intending that the patient should die? If so, this does not represent “killing”. On the other hand, if the intent was clearly that the patient should die, whether beneficent or not then the act would represent “killing”. Obviously, physicians who perform the act will do so with the former intent. That is one view of the distinction. However, there are some life supporting treatments which have been used as examples where the distinction is based on whether the treatment can represent a substituted organ. Applying this view, the action represents removal of a vital organ and death is no longer related to the underlying disease but in the act of organ removal itself. This distinction has been considered rather hazy but consider the following examples:

In a quadriplegic patient who cannot breathe on his or her own, if a ventilator machine has provided a period of life sustaining function that only normal lungs and normal spinal cord conduction could provide, the ventilator might be interpreted as an artificial and substituted “organ” which has become part of the patient’s body. Removing the ventilator function might be the same as taking out both lungs of a normal person, clearly a “killing” act.

Another similar example would be that of a patient who requests turning off of a cardiac pacemaker, which had been inserted to prevent the heart from stopping because of a diseased heart with a complete heart block condition. This pacemaker represents now a part of the patient’s body, in place of the diseased pacemaker mechanism, to keep the heart beating. Turning off the implanted pacemaker would be like the injection of a chemical into a normal person to stop the heart from beating.

One could argue that, as in the Schiavo case, the feeding tube inserted thru the abdominal wall and into the stomach to provide nutriments and fluids essential for life has become for the patient the new “organ” substituting for the patient’s own swallowing mechanism and esophagus, connecting the mouth to the stomach, which may be lost forever. If the tube were removed, it would be like disconnecting the mouth from the stomach in a normal person.

In each case, if one considers the proposition logical, then the act would represent the removal of a normally functioning but substituted “vital organ” and this act would not be considered simply allowing the patient to die from his or her underlying illness and could be considered “killing” regardless of the intent.

I present this issue to point out that the concept of the autonomous request by a patient for someone to discontinue an unwanted therapy is not a simple request devoid of any controversy. It is this uncertainty beween killing and letting die which may give healthcare providers a moral pause when considering whether to accept the patient’s request. ..Maurice.

3-19-2005 Addition to My Posting

Today DB's Medical Rants wrote about my discussion here of this issue. I posted the following comment to that fine medical blog:

I should make it clear (and I only used the word "hazy" in my piece)that the concept of the removal of an "artificial organ" that was functioning as the life-supporting natural organ representing a "killing" is NOT generally considered and is NOT the current ethical consensus. However, this view has been discussed in ethics literature in the past. The currently, the ethical consensus accepted as distinguishing betwee "killing" or "letting die" is simply that of the intent of the one performing the act. I also should make clear that the word "killing" is a term used as the opposite of the condition where the patient is dying because of the lethal effect of the underlying illness ("letting die"). I don't think the ethical view is that of a homicide if the patient cannot perform the act on his/her own. Whether one wants to consider this act "assisted suicide" depends on whether one wants to ignore that the act is NOT one of directly causing death but following the autonomous patient's decision to stop unwanted treatment with the death being caused by the underlying illness.

In "assisted suicide" such as practiced in the state of Oregon, the immediate death is due directly to the pills prescribed and not due to the patient's underlying illness. I hope this explains the current understanding of the issue. In the Schiavo case, the issue is not one of "killing", it is simply one of a legal surrogate requesting that the patient's wishes be followed regarding unwanted treatment. ..Maurice.