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.