More on the Issue of Killing vs Letting Die
Back on October 14 2006, I had a posting about a case of a quadriplegic who required the ventilator for survival but finally wanted it turned off. The issue was if the physicians or others turned off the ventilator would this represent a killing or letting the patient die of his underlying paralysis. Patients have a legal and ethical right to terminate unwanted treatment.
I wanted today to present another killing vs letting die situation for consideration. Cardiac pacemakers are inserted into patients whose heart cannot beat without electrical assistance or on its own beats so slowly that the patient is very symptomatic and if not improved the patient may die from stroke or heart failure.
There are two case scenarios discussed at the American Medical Association’s Virtual Mentor (link 1, link 2) which deal with the issue of the ethics involved in turning off cardiac pacemakers. Read them, return and indicate whether you feel that removing a device attached to preserve the life of a patient who would otherwise die is an intentional killing act such as euthanasia or murder. ..Maurice.
posted by Maurice Bernstein, M.D. @ 8:54:00 PM
11 comments
11 Comments:
I do not see the situation as euthanasia or murder. To euthanize or murder someone is to violate their autonomy and their right to life by taking their life without their consent. The patients in these scenarios know what they want. To help them carry out their wish to die is not murder. Although no doctor who feels it would be unethical should be made to help a patient carry out his wish to die (that would violate the doctor's autonomy as well), helping a competent patient die according to his wishes respects his autonomy and his right to do as he wishes with his own life. The doctor is not committing a moral or ethical wrong against another person.
As a side note, the first scenario mentions urging the patient to get another opinion. Could this end up not being the most ethical thing to do? In the case of a patient with an aggressive disease and short life expectancy, insisting that he go from doctor to doctor until he can prove he has exhausted all possible discussions of the risks and benefits of his decision could be a passive way of avoiding deciding whether to help him.
Lisa, I agree with your commentary. However, I must clarify the act of euthanasia in humans. Euthanasia, as usually defined and where it is practiced (notably in the Netherlands) is not performed without the consent of the patient. (There is concern, however, of slippery slope possibilities where classes of patients who have no capacity for informed consent might be subjected to euthanasia.) However, since euthanasia does represent the intentionally termination of life through the act of another party, one could call that act "killing". Physician assisted suicide (PAS)as defined and as used in the state of Oregon, the physician simply writes a prescription for a lethal dose of pills which the patient may or may not fill and may or may not take at the patient's own discretion. In PAS, the physician's participation is only that of writing a prescription and not personally administering some drug to cause the patient to die.
Obviously, murder is the act performed without the consent of the murdered victim. ..Maurice.
Ignoring the existential/emotional issues at play in this scenario...
It is perfectly acceptable for Jim to request and his physician to discontinue his 'pacemaker treatment.' We have very few absolutes in medicine but one of them is a competent patient's right to say "No" to any treatment, even if life-prolonging (which Jim's pacemaker may not even be). This is straightforwardly everyone's right - to reject or withdraw medical treatments that are not meeting a meaningful 'goal' for the patient (even if that goal is life prolongation).
The issue with pacemakers seems to be that once implanted they are a very low-risk, low-burden treatment. A lot of rhetoric surrounding withdrawing of life prolonging treatments at the end of life focus on this idea of 'burden' (CPR, ventilator, being in the hospital, IV's, whatever). While this is important (particularly to the patients who find them burdensome!) it is not the fundamental reason why it's ok to stop them. It's OK, right, to stop them because they aren't meeting a goal for the patient - restoring function, restoring health, etc. and are only prolonging dying or whatever the scenario is. I think it's emotionally easier for docs to stop treatments they think are burdensome because they don't want to do 'further harm.' Thus, discontinuing an ICD (implanted defibrillator - that can give a patient painful shocks) is seen as OK because you're preventing a painful shock. Stopping a pacemaker...well...you're not preventing much of anything other than unwelcomed life-prolongation. This is much tougher for many clinicians to stomach.
One way I frame it to colleagues (particularly residents) who are struggling with this (although stopping a pacemaker at the end of life is very rare): If the same patient were to suddenly develop a life-threatening brady-arrhythmia that would require a pacemaker and he said "No way, I don't want one. I'm dying of cancer anyway...this is the way I want to go. You can't make me have a pacemaker." Most of us would be comfortable not starting this treatment. Well if we're comfortable not starting it we should be comfortable stopping it. (To be fair, this analogy isn't quite perfect - the act of implanting the pacemaker has pain and risk involve but I've found it a quite effective didactic technique for discussing such issues).
Love the blog, by the way, Maurice.
Drew from Pallimed (www.pallimed.org).
Drew, I would agree that stopping a life-supporting treatment should be looked upon as morally no different than not starting a life-supporting treatment. However, beyond the pain and risk of starting some treatments, there is another difference which might be taken into consideration by a physician comparing the two acts.
In not starting a life-supportive treatment, there has been no absolute proof that the treatment would be effective and no emotional investment into that treatment. By terminating a life-supporting treatment, it means stopping a treatment that has already been proven effective and the patient and even the physician already have some emotional investment in the carrying out of the procedure. In the latter case, the treatment has already become part of the patient. In the former case, no attachment has yet been made. So it is easy to see the greater ease of not starting a presumably life-supporting procedure. ..Maurice.
Clarify for me: If I'm completely paralyzed but certain I wish to end my life, and you inject me with morphine to bring that about, have you euthanized me or helped me commit suicide?
Although in the past, euthanasia (peaceful or good death) has been expressed as either direct or active (the physician performs the act which directly leads to the death of the patient) or indirect (where the physician simply aids the patient to accomplish the act), the latter is now termed "physician assisted suicide"(PAS). Usually now, when the term euthanasia is used it implies that the physician has performed the act. Therefore, Lisa, in your example, if the physician performed the injection, it would be euthanasia and not simply helping to commit suicide as in PAS. ..Maurice.
I have to say, from my own experience with my father and a friend, euthanasia is not only done but condoned.
My friend, in hospice with cancer was "snowed", given morphine at times and doses sufficient to build up nd 'kill' her.
(It was the most kind and humane thing that could have happened to her.)
My father, at home, had ALS and was afraid to die so highly agitated. The doctor said that giving him a med to calm him would most likely kill him.
He was given the drug, went into coma and died a few days later (off of all water and food and without any visible signs of discomfort)
Removng a pacemaker. That is a much more active behavior in (most probably)inducing death.
It seems to me, as a non-lawyer, non-medical person, that the legal system could well have a say as to whether it is euthanasia or murder.
Most of these things are done on the Q.T. with only the immediate family and necessary medical personnel knowing it is going on.
Removing the pace-maker potentially involves more non- essential people, increasing the chances of someone calling in the authorities for a legal position.
Hi, Carol L. Regarding your comment: "euthanasia is not only done but condoned". The treatments you referred to are Palliative treatments. Many palliative treatments -the intention of which is to "relieve" suffering, and not to kill, may indeed precipitate death as a secondary effect. They are only administered as a last resort if considered effective to alleviate physical pain or extreme physical discomfort. Unlike euthanasia, the drug is not administered with the intent to kill. It is a "subtle" but important difference. On a case I reviewed recently, a doctor chose to administer a heavy dose of potassium chloride in lieu of morphine. While a higher dose of morphine may have hastened the patient's death, it was the continuation of a palliative treatment. Unlike this, potassium chloride had no pain-relieving purpose or effect other than the immediate killing of the sufferer!
It is a fine line, but an important one. Hospice does not kill their patients, it's against their mission.
Aline
Though as a physician but also as a member of the "society" of humans, I am opposed to euthanasia BUT I would never withhold the appropriate use of morphine, not to kill but to relieve pain and suffering through morphine's pharmacologic effects. If the patient would die associated with the administration, I would feel that the Principle of Double Effect would apply and my conscience would be free of doubt or concern. ..Maurice.
I need closure.. badly.. my uncle was in icu in MA.. im in from tn and drove up.. when we got there he was bad he had jandice and liver and kidneys had shut down.. to come to find out he had an infection in his tummy that they had not treated in the week he was there.. they could not give him any pain meds and he did look in pain.. but he was compeletely cohearent understood everything everyone was saying and blinked to answer questions.. he was scared and did not want to die he wanted to treat the infection and see what happen i wanted that for him as well.. cause what if he would make it if they treated it but it wasnt his choice it seemed.. everyone just wanted him to go and not to suffer but who was to tell he was really hurting.. he said he didnt wanna die but nurses came in and said we had to choose put on a respirator or to take off eerything and let him pass by giving him morphine.. they gave him pottasium said his blood sugar low .. like two things of it seemed t much to follow by about 3 things of morphine which seemed to od him.. they took him off breathing and everything and it seemed be died from not being able to breath he died wit eyes open.. i think that they od'd him against his will.. will those two things interveinolusly kill him? a women that was not related was one who told doctors to let him go.. he did not want to but couldnt talk for himself.. did they help himcomit suicide?
Amanda Lee, the decision of whether to remove life support and allow the patient to die from the underlying illness or continue life support is one made by the patient at the time of the decision or by the legal surrogate or others who know the patient and could express what the patient may have wanted. If there is a conflict between the doctors and the patient or those speaking for the patient then the hospital's ethics committee should be made aware of the conflict and should mediate a discussion of the issue between the two parties. In the United States, a patient can request that life support be terminated and the death of the patient from the underlying illness is not considered suicide. ..Maurice.
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