Intent and the Dying Patient: What Acts are Legal and What Acts are Ethical?
What is the intent of those who initiate an act and how can one tell if the intent is ethical or legal? Try thinking about this question these two cases. Both were real cases and in both the patients are in the very terminal stages of their illness and each is expected to die in hours, if not in 2 days or less.
CASE A: The patient has lactic acidosis, shock, adult respiratory distress syndrome, disseminated intravascular coagulation and renal failure due to a gangrenous leg and the acidosis is rapidly progressing. The patient is unconscious and appears comfortable. The family, speaking for the patient, refuses a last ditch amputation of the leg after being told that this most likely may not save the patient’s life. The family wants the vasopressors (which is used to attempt to keep the blood pressure towards the normal range) and other IV support terminated since the treatment is now futile for the patient’s recovery. They do want the ventilation treatment continued. It is expected that the patient will die in a few minutes with the vasopressors absent. After an hour, the patient has not expired but is still unconscious. At that point, the family requests that the ventilator be disconnected and here one might infer that the intent was to finally bring the patient’s life to an end while the family is at the bedside. This is done and the patient promptly dies.
CASE B: The patient is dying from end-stage cancer and is receiving a morphine drip and appears quite comfortable according to the nursing staff. The family, however, has requested the physician to increase the morphine drip to a rate which would cause the patient’s death presently. Presumably, the intent is to bring the patient’s life to an end. The physician agrees and writes the order. The nurses refuse to carry out this order and the patient continues living at that time.
Do you see a difference in intent between these two families? It seems that the intent of the family in both cases was to finally and completely terminate the illness (and the patient’s life) even though in both cases the patient was not apparently suffering. The patient is dying and will be dead soon so “why not die now?” might be the argument. The intent seems to be the same in both cases, the natural trajectory of the illness to death may well be about the same but the precipitating actions are different: terminating life support and allowing the patient to die earlier from the underlying disease without that life support is considered legal. In the second case, it is the administration of a dose of morphine which, by the action of the narcotic, knowingly will bring the the patient’s life to an end sooner than if not administered. Such an act could be looked upon as illegal killing.
But is there really no ethical difference between the two acts since both were ethical to end the patients’ illness or were both unethical because neither patient was acutely suffering and therefore the acts may have been for the self-interest of the families (to end the family's distress}? On the other hand, perhaps these cases may be examples of the belief that the real intent of those who advise or perform an act can’t really be guessed. What do you think? ..Maurice.
posted by Maurice Bernstein, M.D. @ 10:30:00 PM
17 comments
17 Comments:
Case A: I am aware of the intent. On the basis of moral grounds the family's intention was to perhaps stop "the suffering". However, no consequential responsibility is discussed for a "what if" scenario. Rehabilitation on the basis of social role valorisation.
Case B: I gather from this case a role of professionalism at stake. What is professionalism? Who is in charge?
Please, correct me if I am wrong I am a student wanting to gain perspective on ethics and its application in a disability field
Ashita, in Case A, what do you mean by "Rehabilitation on the basis of social role valorisation"? Can you present the same statement but with different words?
In Case B: Yes, the physician succumbed to the family's wishes for more morphine than was medically indicated. This represented a breakdown of the physician's professional responsibility to maintain the patient's present comfort but not administer medication at a dose which can kill the patient unless the administration is consistent with the requirements of the principle of "double effect"-- that is essentially in order to provide comfort a dose of morphine which may have the potential to kill the patient could be administered if there was no other less risky way to provide comfort and that the intent was only to provide comfort and not end the patient's life. The patient was already comfortable from the current morphine drip, so giving additional morphine was unnecessary and the intent would have been for some other reason. Finally, such a request by the family should have been refused by the physician and since it was not this represented another unprofessional behavior. ..Maurice.
By "rehabilitation on the basis of social role valorisation" I meant perhaps the stakeholders attending the needs of the patient is putting his/her best interest at the fore front.
Its a holistic approach.
"The major goal of SRV is to create or support socially valued roles for people in their society, because if a person holds valued social roles, that person is highly likely to receive from society those good things in life that are available to that society, and that can be conveyed by it, or at least the opportunities for obtaining these. In other words, all sorts of good things that other people are able to convey are almost automatically apt to be accorded to a person who holds societally valued roles, at least within the resources and norms of his/her society."
http://www.socialrolevalorization.com/resource/OSBURN_SRV.htm
Ashita, thanks for defining SRV and providing the link, however I am still confused with regard to how you are applying SRV to Case A. When you write "the stakeholders attending the needs of the patient is putting his/her best interest at the fore front". are you referring "putting his/her best interest" to the stakeholders or to the unconscious dying patient? The reason I ask that is that family members who must "speak" for a patient who has no capacity to speak or make medical decisions for themselves must make a decision first as to what the patient him/herself had wanted and if unknown then in the best interest of the patient. The surrogate decision-maker should not be directing the decision based on the best interests of the surrogate themselves.
In Case A, the patient is unconscious and slowly dying but is apparently unconscious and unaware. Is it in the patient's best interest when finding that turning off the vasopressor did not cause prompt death that it would be next appropriate to turn of the ventilator, perhaps motivated by a desire of the family to be in attendance when the patient died? On the other hand one might say if the patient is already on a irreversible trajectory for death, it is time to look to the best interests of others and no longer the patient. The others could be the family but it also could be those patients who are in need of the resources being used by the dying patient.
Again, thanks for the definition and link since I was unaware of Doctor Wolfensberger's concept. ..Maurice.
The medical profession must not hasten death by intent. This violates our oath and our professional and ethical obligation to the patient. I address this issue in current posting at www.MDWhistleblower.blogspot.com regarding organ donation. Imagine how slippery the slope would become if tissue banks, organ harvesters and dying patients in need of organs were involved in revising current policy. They would argue that the ends would justify the means. One life must not be sacrificed to save another.
Of course, in general, the medical profession should not hasten death by intent. That is why I am against even physician assisted suicide. I cannot believe that a physician prescribing a lethal dose of barbiturate to a patient despite knowing that the patient might not decide to take the pills could say that the such a prescription was not a facilitator for the patient's hastened death.
However, the argument gets a bit sticky when dealing with vital organ procurement and transplant. In this case, the patient or the family acting as surrogates for the patient has approved organ procurement for transplant along with termination of life support in the patient who has no chance for survival. And here is the sticky part: It may be necessary to do some things to facilitate the continued functioning of the vital organ when it is finally transplanted into the recipient patient's body. Those things might involve administering chemicals to the donor patient to preserve function. These chemicals may also in fact accelerate the death of the patient. Those things might also involve waiting for a shorter time period with the heart not beating to declare the patient dead and then allow the immediate removal of the organs. Each of these two acts "hasten death" and yet they are done for the beneficence of the recipient to whom the organ was directed when the donor is about to no longer need medical professional duties.
Interestingly, the administration of chemicals has been forbidden, the role of the patient's physician has been removed from requesting donation permission or involvement in the procurement or transplant process but only permitted to pronounce death. And now there is concern that the waiting time before the pronouncement of death when the heart has stopped may be too short in some cases.
However, one wonders whether the ethical intent of organ transplant when approved by the patient and family should be directed at the best preservation of transplant organ function for the recipient and no longer any obligation for the donor. What do my visitors think? ..Maurice.
Dr. Bernstein,
I see the two situations as ethically very different. To me there is a huge difference between withholding or terminating life support (situation A) in order to allow death to occur naturally, and actively administering or increasing dosage of a drug that will have no therapeutic value to the patient - with the only result being to hasten death (situation B).
With respect to organ donation, I believe that the beneficence of the recipient must always be secondary to any harm done to the donor. Those involved in organ procurement should never have any involvement in the planning of or care for the potential donor prior to the declaration of death. I have a particular ethical problem with DCD when the heart is one of the organs to be harvested, and agree with ethicists that equate such action to homicide by organ donation.
While I have no quarrel with those that do, I personally do not believe in organ/tissue donation. To that end, I have included detailed instructions in both my advanced directive and supplemental instructions to my personal health care representative that specifically prohibit both donation and any action intended to facilitate donation.
I also have no problem with physician assisted suicide as enacted into law by the states of Oregon and Washington. The physician is not actively administering drugs to the patient, but simply making them available to the patient so they can, if they choose, exercise their rights under the law.
Hexanchus, thanks for your contribution to this discussion. I would like to make some comments about a couple of your statements. First, you write "With respect to organ donation, I believe that the beneficence of the recipient must always be secondary to any harm done to the donor." I think in the specific situation of a recipient who has the potential by transplant to life and the donor who has no expectancy for further life, that the application of beneficence should be proportional to its life value to each. Nevertheless, I do agree that those who care for the donor during life should not participate in any part of the approval process or organ procurement or transplant. I also agree with the "dead donor" rule that potential donors not be physically managed as such until they are pronounced dead. An exception would be, with the patient's or family's permission to delay terminating life-support until the procurement team is present and able to act. I would also agree with "death by neurologic criteria" since I think that if the criteria are strictly followed such a patient has without a doubt lost forever the personhood of life and is dead and even with mechanical ventilation the heart will cease beating if not in a day or two, very shortly.
I am concerned, however, about unusually premature declaration of death in patients who are candidates for "donation by cardiac death" (CDC). I think that periods shorter than 5 minutes of asystole (absent heart beat) is ethically inappropriate even though any resuscitation attempt is out of consideration and therefore clinically meaningless. I say "ethically inappropriate" not out of concern of beneficence to the patient (as I have suggested above) but more out of it being unprofessional to declare a patient dead when theoretically, if resuscitation was attempted, the patient's immediate course would not necessarily always be death.
Finally, with regard to physician assisted suicide, you write: " The physician is not actively administering drugs to the patient, but simply making them available to the patient so they can, if they choose, exercise their rights under the law." But the intent of the physician in prescribing such a known lethal, non-standard therapeutic dose is to promote the death of the patient as the patient desires. There is a difference between this act of the physician and a physician or nurse or respiratory tech who turns off the ventilator at the request of the patient as unwanted treatment. Yes, the final outcome is death and the physician is aware but in reality it is the underlying illness and pathology of the patient that is the cause of death and not simply the removal of the source of ventilation. The caregiver's intent is to follow the legal and ethical decision of the patient regarding unwanted life-supportive treatment. In the case of the prescribing of pills, it is the pills and not the underlying disease that is the immediate cause of death and the intent of the physician is that the dose of the pills will be sufficient to cause the death of the patient. ..Maurice.
DR. Bernstein,
Thanks for your comments in response to my earlier post.
You write "An exception would be, with the patient's or family's permission to delay terminating life-support until the procurement team is present and able to act. I would also agree with "death by neurologic criteria" since I think that if the criteria are strictly followed such a patient has without a doubt lost forever the personhood of life and is dead and even with mechanical ventilation the heart will cease beating if not in a day or two, very shortly." I agree with you on this.
You also wrote "I am concerned, however, about unusually premature declaration of death in patients who are candidates for "donation by cardiac death" (CDC). I think that periods shorter than 5 minutes of asystole (absent heart beat) is ethically inappropriate even though any resuscitation attempt is out of consideration and therefore clinically meaningless. I say "ethically inappropriate" not out of concern of beneficence to the patient (as I have suggested above) but more out of it being unprofessional to declare a patient dead when theoretically, if resuscitation was attempted, the patient's immediate course would not necessarily always be death." I also agree with you on this - my concern with DCD is that "irreversible" is exactly that, whether or not there is any intent to resuscitate.
With respect to physician assisted suicide, you commented "The caregiver's intent is to follow the legal and ethical decision of the patient regarding unwanted life-supportive treatment. In the case of the prescribing of pills, it is the pills and not the underlying disease that is the immediate cause of death and the intent of the physician is that the dose of the pills will be sufficient to cause the death of the patient." On this we disagree. I believe that in prescribing the pills, the intent of the physician is, in fact, to follow the legal and ethical decision of the patient to exercise their rights under the law. Whether the patient chooses to actually use the prescription (and many don't) is solely up to the patient. I see this as very different from a physician actively administering an agent to the patient to cause death.
Certainly a physician that morally objects to the process should not have to participate in it, but I don't see the actions of a physician that chooses to participate as unethical....just my $0.02.....
Hexanchus, the professional duty of a physician is to attempt to preserve life up to the point where further specific treatment is futile with regard to that goal. Palliative treatment to reduce pain and suffering, of course, should never be considered futile and the physician's duty is to continue that comfort care to the point of death. However, I don't believe that prescribing a deadly dose of pills to a patient who may be weeks or literally months or more away, even perhaps years, from death represents the palliative care that the physician should be obliged to perform as part of his or her profession. Yes, if the request for pills is due to depression or other psycho-social issue,that should be investigated and then actively treated. If society agrees that writing a prescription for a lethal dose of drugs in response to a patient's request for death is justified, ethical and will become legal then society should go ahead with the option. But the ones who provide the pills should not be physicians and should not be pharmacists but society-created technicians whose occupation is meeting the patient's request by directly dispensing those pills from supplies provided by society.
Let the physicians only perform diagnosis and treatment and palliation for the underlying medical or psychiatric condition and confirm prognosis but not contribute their skills and license to the death of the patient. ..Maurice.
Dr.Bernstein,
Regarding your comment: "I think in the specific situation of a recipient who has the potential by transplant to life and the donor who has no expectancy for further life, that the application of beneficence should be proportional to its life value to each." If I understand you comment correctly, you are assigning relative values of life to different human beings, depending upon their individual circumstances. I reject this as it would inevitably lead to trying to assign life value by income, occupation, age, education, etc. I think that this approach is ethically unsupportable. My own views on organ donation and physician-assisted suicide is covered in prior 2 postings at www.MDWhistleblower.blogspot.com. As discussed there, the Montana Supreme Court heard a case this past wk where plaintiff argues there is a constitutional right to physician-assisted suicide.
Dr. Kirsch, as I hope I implied in my statement "I think in the specific situation of a recipient who has the potential by transplant to life and the donor who has no expectancy for further life, that the application of beneficence should be proportional to its life value to each", what I was expressing was not intended to be a generalization but was related to that "specific situation". The specific situation involved a patient, the donor, who was certain to die with essentially no period of delay and a patient, the recipient, who would be dead at some future time because of a non or poorly functioning organ but with the organ transplant from the donor, the recipient's life could be highly extended. The donor has no further relative "life value", the recipient has. Therefore, in this isolated situation where death is imminent for one but with the death an opportunity to a prolonged life for the other, the application of beneficence should be proportional to its "life value" to either. This view of "life value" cannot hold in any other situation since obviously the value of further life is a quantity that only the patient who will live the life can make and no one else. ..Maurice.
You may be interested in reading another case where the intent of a family to turn off a patient's cardiac pacemaker is questioned. Click on the following link. ..Maurice.
Dr. Bernstein, It still seems to me that it is your view that a person's life at the end of life is worth less than a younger life, who may need organs, etc. Do you believe that everyone's life is of equal value? I will comment further once I understand your view on this fundamental question. Thanks.
Dr. Kirsch, the situation which I am writing about and hopefully you are also considering is a unique one and is not readily found similar in any other situation. There is a relationship which has been already established between two individuals. One is on the verge of death without any intent for resuscitation who will provide a vital organ for another individual who is not on the verge of death but can die soon without that organ and with the organ may continue to have a life. Surely there is more than a quantitative time difference between the two individual's remaining life. I suggest there is a qualitative difference and that qualitative difference may evoke a differential (proportional) difference between the beneficent acts of healthcare providers for these two individuals. This has nothing to do with comparing "everyone's life" nor the lives of the elderly vs the young since as I said the value of one's life is set only by the individual.
I can show you examples of proportional differences in beneficence that occur in this situation. A decision is made by the patient or surrogate speaking for the patient to terminate life-support and bring the patient's suffering to an end. However, vital organ donation was also a decision by the patient/surrogate (Donation by Cardiac Death). While there is urgency to, after removal of the organ, transport and transplant it into the recipient (for the benefit of the recipient: better functioning transplant organ) there may not be the urgency to discontinue life support for the donor, despite the request, in order to get the procurement team in place and establish and maintain the best organ perfusion for its removal and transplant. The goal is do the best for the recipient by prompt transplant of the removed organ even though there may be a delay (and thus less best) in carrying out the wishes of the donor to promptly terminate life support. Thus, there is difference in beneficence applied to each party. The same unequal beneficence may be occurring currently in Donation by Cardiac Death since there is reported a tendency for some physicians to pronounce death earlier than after at least 5 minutes of cardiac standstill. Again, facilitating better organ status for the recipient and perhaps less ethical beneficence to the donor. The argument is that since there will be no cardio-pulmonary resuscitation attempt on the donor, pronouncing death a couple minutes earlier after cardiac arrest is ethical.
I hope these examples practiced in procurement and transplant of organs will help to clarify why I state that there may be proportional beneficence. And this is all related to the qualities of remaining life, but only in this special relationship of individuals. ..Maurice.
Dr. Bernstein, I follow your reasoning and would find it more persuasive, perhaps, if I were in the presumed recipient's family. I do find the notion of making qualitative life assessments to be troubling. Why wouldn't your logic not hold if the 'donor' was not on the verge of death, but was merely elderly, or demented, or paraplegic, etc? Explain why your logic wouldn't permit these people from being regarded as potential donors? Could your extreme 'verge of death' example be the first brick in a wall of ethical abuse? www.MDWhistleblower.blogspot.com
On the "verge of death", meaning to me certain death within a matter of hours, while there may be some quality of life in those remaining minutes, the organ recipient would have potentially an opportunity for a much broader, extensive and variable quality of life ahead. With regard to the "elderly or demented, or paraplegic, etc" none are on the "verge of death" and each has the ethical autonomy and opportunity to describe their own assessment of quality of their remaining life they desire if they haven't already done so previously. They have a life, the patient on the "verge of death" has virtually none. That's the difference. Since the donor-recipient relationship is unique, I would not defend thet "proportional beneficence" being applied elsewhere. ..Maurice.
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