资料安乐死euthanasia
What is palliative care?
Palliative care is specialised care and support provided for someone living with a terminal illness（晚期病症）. Importantly, palliative care also involves care and support for family and caregivers（护理者）. The goal of palliative care is to improve quality of life for patients, their families and caregivers by providing care that addresses（满足需求）the many needs patients, families and caregivers have: physical (including treatment of pain and other symptoms), emotional, social, cultural and spiritual. Palliative care aims to help the patient live as well as possible. Palliative care offers support to help family and caregivers manage during the patient’s illness and in bereavement(亲人丧亡). As a person receiving palliative care, the patient is an important partner in planning their care and managing their illness. When people are well informed, participate in treatment decisions and communicate openly with their doctors and other health professionals, they help make their care as effective as possible.
Care planning is an important process in ensuring the patient’s wishes, in relation to their care, are met. Patients should speak to their doctor about advance care planning and advance care directives.
1. What is Euthanasia?
Euthanasia is the termination of a very sick person's life in order to relieve them of their suffering.
A person who undergoes euthanasia usually has an incurable condition. But there are other instances where some people want their life to be ended.
In many cases, it is carried out at the person's request but there are times when they may be too ill and the decision is made by relatives, medics（医护人员）or, in some instances, the courts.
The term is derived from the Greek word euthanatos which means easy death.
Euthanasia is against the law in the UK where it is illegal to help anyone kill themselves. Voluntary euthanasia or assisted suicide can lead to imprisonment of up to 14 years.
The issue has been at the centre of very heated debates for many years and is surrounded by religious, ethical and practical considerations.
The ethics of euthanasia
Euthanasia raises a number of agonising（痛苦）moral dilemmas
:
?is it ever right to end the life of a terminally ill patient（患有不治之症的病人）who is undergoing severe pain and suffering?
?under what circumstances can euthanasia be justifiable, if at all?
?is there a moral difference between killing someone and letting them die?
At the heart of these arguments are the different ideas that people have about the meaning and value of human existence.
Should human beings have the right to decide on issues of life and death?
There are also a number of arguments based on practical issues.
Some people think that euthanasia shouldn't be allowed, even if it was morally right, because it could be abused and used as a cover（幌子，伪装）for murder.
Killing or letting die
Euthanasia can be carried out either by taking actions, including giving a lethal injection, or by not doing what is necessary to keep a person alive (such as failing to keep their feeding tube（喂食管）going).
'Extraordinary' medical care
It is not euthanasia if a patient dies as a result of refusing extraordinary or burdensome medical treatment（特殊或繁重的药物治疗）
.The act or practice of ending the life of an individual suffering from a terminal illness or an incurable condition, as by lethal injection or the suspension of extraordinary medical treatment.
安乐死个别患者因病情到了晚期或不治之症，不愿再受病痛折磨而采取的了结生命的措施，一般采用注射致命物质或中断特殊治疗方法
Euthanasia and pain relief
It's not euthanasia to give a drug in order to reduce pain, even though the drug causes the patient to die sooner. This is because the doctor's intention was to relieve the pain, not to kill the patient. This argument is sometimes known as the Doctrine of Double Effect.（双重效果），一些行为不可避免地将带来双重效果：意愿中的好的结果和预见到的不想要的效果
Mercy killing
Very often people call euthanasia 'mercy killing', perhaps thinking of it for someone who is terminally ill and suffering prolonged（长期的）, unbearable pain（不堪忍受的痛苦）.
Why people want euthanasia
Most people think unbearable pain is the main reason people seek euthanasia, but some surveys in the USA and the Netherlands showed that less than a third of requests for euthanasia were because of severe pain.
Terminally ill people can have their quality of life severely damaged by physical conditions such as incontinence, nausea and vomiting, breathlessness, paralysis and difficulty in swallowing.
Psychological factors that cause people to think of euthanasia include depression, fearing loss of control or dignity, feeling a burden, or dislike of being dependent.
2. Ethical problems of euthanasia
Does an individual who has no hope of recovery have the right to decide how and when to end their life?
Why euthanasia should be allowed
Those in favour of euthanasia argue that a civilised society should allow people to die in dignity and without pain, and should allow others to help them do so if they cannot manage it on their own.
They say that our bodies are our own, and we should be allowed to do what we want with them. So it's wrong to make anyone live longer than they want. In fact making people go on living when they don't want to violates their personal freedom and human rights.It's immoral, they say to force people to continue living in suffering and pain.
They add that as suicide is not a crime, euthanasia should not be a crime.
Why euthanasia should be forbidden
Religious opponents of euthanasia believe that life is given by God, and only God should decide when to end it.
Other opponents fear that if euthanasia was made legal, the laws regulating it would be abused, and people would be killed who didn't really want to die.
The legal position
Euthanasia is illegal in most countries, although doctors do sometimes carry out euthanasia even where it is illegal.
Euthanasia is illegal in Britain. To kill another person deliberately is murder or manslaughter, even if the other person asks you to kill them. Anyone doing so could potentially face 14 years in prison.
Under the 1961 Suicide Act, it is also a criminal offence in Britain, punishable by 14 years' imprisonment, to assist, aid or counsel somebody in relation to taking their own life.
Nevertheless, the authorities may decide not to prosecute in cases of euthanasia after taking into account the circumstances of the death.
In September 2009 the Director of Public Prosecutions was forced by an appeal to the House of Lords to make public the criteria that influence whether a person is prosecuted. The factors put a large emphasis on the suspect knowing the person who died and on the death being a one-off occurrence in order to avoid a prosecution.
(Legal position stated at September 2009)
Changing attitudes
The Times (24 January 2007) reported that, according to the 2007 British Social Attitudes survey, 80% of the public said they wanted the law changed to give terminally ill patients the right to die with a doctor's help.
In the same survey, 45% supported giving patients with non-terminal illnesses the option of euthanasia. "A majority" was opposed to relatives being involved in a patient's death.
3. Living wills
A living will is a document that sets out a patient's wishes regarding health care and how they want to be treated if they become seriously ill and unable to make or communicate their own choices. Living wills are also called active declarations.
Such a document may be helpful to relatives and to medical professionals in the case of a seriously ill and incapacitated patient.
Living wills are a part of planning what to do in the event of serious illness or disability. The phrase has been used as a handy media label to such an extent that many people focus on the document itself, rather than the actual process of advance care planning. It may well be that:
The best discussions and plans for care may never be documented in a discrete, recognisable living will.
Linda Emanuel, vice president ethics standards, American Medical Association
A living will is not an instrument of euthanasia, but a request in advance to doctors not to give certain medical treatments.
In fact, a living will need not block treatment, but could specify that doctors must continue treatment until the patient is dead, regardless of pain or suffering.
A philosophical problem
To make the use of a living will sensible we have to assume that the wishes of the person would be the same when they become incompetent as when they make the will.
There is some evidence that it is much harder to anticipate one's state of mind when dying (or when receiving significant medical treatment) than had been thought, and equally hard, if not impossible, to anticipate what one's state of mind (if any) will be when one is in a coma.
Some people take this further, and say that "an individual is as discontinuous from itself at a later time as it is from other individuals". If you accept this then it's not logical to accept the usefulness of a living will at all.
Advantages of living wills
?They respect the patient's human rights, and in particular their right to reject medical treatment
?Creating them encourages full discussion about end of life decisions
?Knowing what the patient want means that doctors are more likely to give appropriate treatment
?They help medical professionals in taking difficult decisions
? A patient's family and friends don't have to take the difficult decisions Disadvantages of living wills
?Writing them may be very depressing
?It's difficult for a healthy person adequately to imagine what they would really want in the situations where a living will would take effect
?It may be hard to translate the words of the living will into actual medical action
?Patients may change their minds but not change their living wills
?They're no use if they can't be found quickly when needed
When to make one
People in good health find it hard to imagine the whole range of situations that might befall them, so it may be more effective for living wills to be compiled in the early stages of a disease or disability, as this will allow doctors to give realistic guidance about possible future situations.
Attitudes to living wills
A survey reported in the British Medical Journal in June 2000 found that although elderly inpatients were confused by the term "living will", most would welcome the chance to discuss issues about facing the end of life, and many would want to limit their health care if they were terminally ill.
Contents of a living will
Such a document would offer a set of particular medical scenarios (we've used an example prepared by the American Medical Association):
?Vegetative state
?Coma
?Brain damage and terminal
?Brain damage not terminal
?Chronic and incurable
?Serious but treatable
It would allow the patient to specify the goals of their medical care in each scenario from a list:
?Prolong Life; Treat Everything
?Attempt to Cure, but Reevaluate Often
?Limit to Less Invasive and less burdensome interventions
?Provide comfort care only
?Other (please specify)
It would also allow the patient to say what their wishes are in respect of specific medical interventions in the case of each of the scenarios above. They could say for each type of intervention:
?I want this treatment
?I want this treatment tried, but stopped if there is no clear improvement
?I don't want this treatment
?I am undecided about this treatment
The form of living will offered by the UK Voluntary Euthanasia Society also includes a set of medical scenarios and continues in a more general form than the American Version:
I DECLARE that if at any time the following circumstances exist, namely:
?I suffer from one or more of the conditions listed in the schedule; and
?I have become unable to participate effectively in decisions about my medical care; and
?two independent doctors (one a consultant) are of the opinion that I am unlikely to recover from illness or impairment involving severe distress or
incapacity for rational existence,
THEN AND IN THOSE CIRCUMSTANCES my directions are as follows:
?that I am not to be subjected to any medical intervention or treatment aimed at prolonging or sustaining my life;
that any distressing symptoms (including any caused by lack of food and fluid) are to be fully controlled by appropriate analgesic or other treatment, even though that treatment may shorten my life.
I consent to anything proposed to be done or omitted in compliance with the directions expressed above and I absolve my medical attendants from any civil liability arising out of such acts or omissions.
I wish it to be understood that I fear degeneration and indignity far more than I fear death. I ask my medical attendants and any person consulted by them to bear this statement in mind when considering what my intentions would be in any uncertain situation.
History
Living wills were first proposed in 1969 by the American lawyer Louis Kutner as a simple device to allow patients to say no to life-sustaining treatment that they did not want, even if they were too ill to communicate.
They dealt with the problem that doctors often found it hard to accept that patients might prefer death to treatment, especially when the patients could not speak for themselves.
Early attempts at using them revealed many problems in translating the wishes in the documents into specific actions for doctors to take about medical treatment.
Since then the documents have been greatly improved by the development of standards for the valid framing of topics and the elicitation and recording of opinions, wishes, and reasoning.
Medical Power of Attorney
An alternative to the living will is the Medical Power of Attorney which is available in some places.
This lets a person delegate to someone else the authority to make medical decisions on their behalf if they become unable to make or communicate such decisions. Unlike a living will, a MPOA allows the principal to have a wide array of health care decisions made by their agent, not just those directed towards death.
The MPOA only takes effect when a doctor has certified that the patient can no longer take or communicate their own decisions.
Before taking any decision, the chosen agent is expected to discuss things with the patient's doctors, and to take into account their knowledge of the patient’s wishes, including their religious and moral beliefs.
However a 1998 study produced some alarming results about the wisdom of appointing a medical proxy. The study, which used paired interviews, found that
terminally-ill patients and their chosen surrogate health care decision-makers were in agreement on end-of-life choices in only 66% of the cases.
[D. Sulmasy et al., "The Accuracy of Substituted Judgments in Patients with Terminal Diagnoses," Annals of Internal Medicine, 4/15/98, pp. 621-629]
4. Key terms and definitions
Active euthanasia
In active euthanasia a person directly and deliberately causes the patient's death. Assisted suicide
This is when the person who wants to die needs help to kill themselves, asks for it and receives it.
Competence
A competent patient is one who understands his or her medical condition, what the likely future course of the disease is, and the risks and benefits associated with the treatment of the condition; and who can communicate their wishes.
Dignity
The value that a human being has simply by existing, not because of any property or action of an individual.
DNR不得复苏令，不能复苏令
Abbreviation for Do Not Resuscitate. Instruction telling medical staff not to attempt to resuscitate the patient if the patient has a heart attack.
Doctrine of Double Effect
Ethical theory that allows the use of drugs that will shorten life, if the primary aim is only to reduce pain.
Futile treatment
Treatment that the health care team think will be completely ineffective.
Indirect euthanasia
This means providing treatment (usually to reduce pain) that has the foreseeable side effect of causing the patient to die sooner.
Involuntary euthanasia
This occurs when the person who dies wants to live but is killed anyway. It is usually the same thing as murder.
Living will
A document prepared by an individual in which they state what they want in regard to medical treatment and euthanasia.
Non-voluntary euthanasia
This is where the person is unable to ask for euthanasia (perhaps they are unconscious or otherwise unable to communicate), or to make a meaningful choice between living and dying and an appropriate person takes the decision on their behalf, perhaps in accordance with their living will, or previously expressed wishes.
Palliative care
Medical, emotional, psychosocial, or spiritual care given to a person who is terminally ill and which is aimed at reducing suffering rather than curing.
Passive euthanasia
In passive euthanasia death is brought about by an omission - i.e. by withdrawing or withholding treatment in order to let the person die.
PAS
Abbreviation for Physician Assisted Suicide.
Voluntary euthanasia
This is where euthanasia is carried out at the request of the person who dies.
种类types
5. Forms of euthanasia
Euthanasia comes in several different forms, each of which brings a different set of rights and wrongs.
第一种分类：Active and passive euthanasia
In active euthanasia a person directly and deliberately causes the patient's death. In passive euthanasia they don't directly take the patient's life, they just allow them to die.
This is a morally unsatisfactory distinction, since even though a person doesn't
'actively kill' the patient, they are aware that the result of their inaction will be the death of the patient.
Active euthanasia is when death is brought about by an act - for example when a person is killed by being given an overdose of pain-killers.
Passive euthanasia is when death is brought about by an omission - i.e. when someone lets the person die. This can be by withdrawing or withholding treatment:
?Withdrawing treatment: for example, switching off a machine that is keeping a person alive, so that they die of their disease.
?Withholding treatment: for example, not carrying out surgery that will extend life for a short time.
Traditionally, passive euthanasia is thought of as less bad than active euthanasia. But some people think active euthanasia is morally better.
Read more about the ethics of passive and active euthanasia
第二种分类：Voluntary and involuntary euthanasia
Voluntary euthanasia occurs at the request of the person who dies.
Non-voluntary euthanasia occurs when the person is unconscious or otherwise unable (for example, a very young baby or a person of extremely low intelligence) to make a meaningful choice between living and dying, and an appropriate person takes the decision on their behalf.
Non-voluntary euthanasia also includes cases where the person is a child who is mentally and emotionally able to take the decision, but is not regarded in law as old enough to take such a decision, so someone else must take it on their behalf in the eyes of the law.
Involuntary euthanasia occurs when the person who dies chooses life and is killed anyway. This is usually called murder, but it is possible to imagine cases where the killing would count as being for the benefit of the person who dies.
Read more about the ethics of voluntary and involuntary euthanasia Indirect euthanasia
This means providing treatment (usually to reduce pain) that has the side effect of speeding the patient's death.
Since the primary intention is not to kill, this is seen by some people (but not all) as morally acceptable.
A justification along these lines is formally called the doctrine of double effect. Assisted suicide
This usually refers to cases where the person who is going to die needs help to kill themselves and asks for it. It may be something as simple as getting drugs for the person and putting those drugs within their reach.
6. Voluntary and involuntary euthanasia
Voluntary euthanasia
The person wants to die and says so. This includes cases of:
?asking for help with dying
?refusing burdensome medical treatment
?asking for medical treatment to be stopped, or life support machines to be switched off
?refusing to eat
?simply deciding to die
Non-voluntary euthanasia
The person cannot make a decision or cannot make their wishes known. This includes cases where:
?the person is in a coma
?the person is too young (eg a very young baby)
?the person is senile （衰老的）
?the person is mentally retarded to a very severe extent
?the person is severely brain damaged
?the person is mentally disturbed in such a way that they should be protected from themselves
Involuntary euthanasia
The person wants to live but is killed anyway.This is usually murder but not always. Consider the following examples:
? A soldier has their stomach blown open by a shell burst. They are in great pain and screaming in agony. They beg the army doctor to save their life. The doctor knows that they will die in ten minutes whatever happens. As he has no painkilling drugs with him he decides to spare the soldier further pain and shoots them dead.
? A person is seen at a 10th floor window of a burning building. Their clothes are on fire and fire brigade has not yet arrived. The person is screaming for help.
A passer by nearby realises that within seconds the person will suffer an agonising
death from burns. He has a rifle with him and shoots the screaming person dead.
? A man and a woman are fleeing from a horde of alien monsters notorious for torturing human beings that they capture. They fall into a pit dug to catch them.
As the monsters lower their tentacles into the pit to drag the man out he begs the woman to do something to save him. She shoots him, and then kills herself. The morality of these and similar cases is left for the reader to think about.
7. Active and passive euthanasia
Active euthanasia
Active euthanasia occurs when the medical professionals, or another person, deliberately do something that causes the patient to die.
Passive euthanasia
Passive euthanasia occurs when the patient dies because the medical professionals either don't do something necessary to keep the patient alive, or when they stop doing something that is keeping the patient alive.
?switch off life-support machines
?disconnect a feeding tube
?don't carry out a life-extending operation
?don't give life-extending drugs
The moral difference between killing and letting die
Many people make a moral distinction between active and passive euthanasia.
They think that it is acceptable to withhold treatment and allow a patient to die, but that it is never acceptable to kill a patient by a deliberate act.
Some medical people like this idea. They think it allows them to provide a patient with the death they want without having to deal with the difficult moral problems they would face if they deliberately killed that person.
Thou shalt not kill but needst not strive, officiously, to keep alive.
Arthur Hugh Clough (1819-1861)
There is no real difference
But some people think this distinction is nonsense, since stopping treatment is a deliberate act, and so is deciding not to carry out a particular treatment.
Switching off a respirator requires someone to carry out the action of throwing the switch. If the patient dies as a result of the doctor switching off the respirator then although it's certainly true that the patient dies from lung cancer (or whatever), it's also true that the immediate cause of their death is the switching off of the breathing machine.
?in active euthanasia the doctor takes an action with the intention that it will cause the patient's death
?in passive euthanasia the doctor lets the patient die
?when a doctor lets someone die, they carry out an action with the intention that it will cause the patient's death
?so there is no real difference between passive and active euthanasia, since both have the same result: the death of the patient on humanitarian grounds
?thus the act of removing life-support is just as much an act of killing as giving
a lethal injection
Is active euthanasia morally better?
Some (mostly philosophers) go even further and say that active euthanasia is morally better because it can be quicker and cleaner, and it may be less painful for the patient.
Acts and omissions
This is one of the classic ideas in ethics. It says that there is a moral difference between carrying out an action, and merely omitting to carry out an action.
Simon Blackburn explains it like this in the Oxford Dictionary of Philosophy:
The doctrine that it makes an ethical difference whether an agent actively intervenes to bring about a result, or omits to act in circumstances in which it is foreseen that as a result of the omission the same result occurs.
Thus suppose I wish you dead, if I act to bring about your death I am a murderer, but if I happily discover you in danger of death, and fail to act to save you, I am not acting, and therefore, according to the doctrine, not a murderer.
Simon Blackburn, Oxford Dictionary of Philosophy
But the acts and omissions doctrine doesn't always work...
The killings in the bath
The philosopher James Rachels has an argument that shows that the distinction between acts and omissions is not as helpful as it looks. Consider these two cases:
?Smith will inherit a fortune if his 6 year old cousin dies.
?One evening Smith sneaks into the bathroom where the child is having his bath and drowns the boy.
?Smith then arranges the evidence so that it looks like an accident.
?Jones will inherit a fortune if his 6 year old cousin dies.
?One evening Jones sneaks into the bathroom where the child is having his bath.
?As he enters the bathroom he sees the boy fall over, hit his head on the side of the bath, and slide face-down under the water.
?Jones is delighted; he doesn't rescue the child but stands by the bath, and watches as the child drowns.
According to the doctrine of acts and omissions Smith is morally guiltier than Jones, since he actively killed the child, while Jones just allowed the boy to die. In law Smith is guilty of murder and Jones isn't guilty of anything.
However, most people would regard any distinction between their moral guilt as splitting hairs.
Suppose Jones defends himself by saying:
I didn't do anything except just stand there and watch the child drown. I didn't kill him; I only let him die.
Would we be impressed?
An objection to this analogy
You might argue that we can't compare the case of a doctor who is trying to do their best for their patient with Smith and Jones who are obvious villains.
Of course you can't. But if you don't find the difference between killing and letting die persuasive in the Smith/Jones case, you shouldn't find it effective in the case of the well-meaning doctor and euthanasia.
The importance of intention
The Smith/Jones case partly depends on us paying no attention to the intentions of Smith and Jones. But in most cases of right and wrong we do think that intention matters, and if we were asked, we would probably say that Smith was a worse person than Jones, because he intended to kill.
Consider this case (and yes, it's a fantasy, doctors don't behave like this):
?Brown is rushed into hospital after being stabbed.
?He arrives in casualty. Although he is bleeding heavily, he could be saved.
?The only doctor on duty wants to go home, and knows that saving Brown will take him an hour.
?He decides to let Brown bleed to death.
?Brown dies a few minutes later.
?Brown's mother arrives, and on learning what has happened screams at the doctor, "You killed my son!"
?The doctor replies, "No I didn't. I just let him die."
No-one would think that the doctor's reply excused him in any way. In this case letting someone die is morally very bad indeed.
And if the lazy doctor defended himself to Brown's mother by saying, "I didn't kill him. The dagger in his heart killed him," we wouldn't think this an adequate moral argument either.
You can probably invent many similar examples.
But there are cases where letting someone die might not be morally bad.
Suppose that the reason the doctor didn't save Brown was that he was already in the middle of saving Green, and if he left Green to save Brown, Green would die. In that case, we might think that the doctor had a good defence against accusations of unethical behaviour.
Further reading
James Rachels, 'Active and Passive Euthanasia'. The New England Journal of Medicine, Vol. 292, pp 78-80, 1975
Preferring active to passive euthanasia
This section is written from the presumption that there are occasions when euthanasia is morally OK. If you believe that euthanasia is always wrong, then this section is not worth reading.
Active euthanasia is morally better because it can be quicker and cleaner, and it may be less painful for the patient.
Doctors faced with the problem of an incurable patient who wants to die have often felt it was morally better to withdraw treatment from a patient and let the patient die than to kill the patient (perhaps with a lethal injection).
But some philosophers think that active euthanasia is in fact the morally better course of action.
Here's a case to consider:
? A is dying of incurable cancer.
? A will die in about 7 days.
? A is in great pain, despite high doses of painkilling drugs.
? A asks his doctor to end it all.
?If the doctor agrees, she has two choices about what to do:
?The doctor stops giving A the drugs that are keeping him alive, but continues pain killers - A dies 3 days later, after having been in pain despite the doctor's best
efforts.
?The doctor gives A a lethal injection - A becomes unconscious within seconds and dies within an hour.
Let's suppose that the reason A wants to die is because he wants to stop suffering pain, and that that's the reason the doctor is willing to allow euthanasia in each case. Active euthanasia reduces the total amount of pain A suffers, and so active euthanasia should be preferred in this case.
To accept this argument we have to agree that the best action is one the which causes the greatest happiness (or perhaps the least unhappiness) for the patient (and perhaps for the patient's relatives and carers too). Not everyone would agree that this is the right way to argue.
We can look at this situation is another way:
?Causing death is a great evil if death is a great evil.
? A lesser evil should always be preferred to a greater evil.
?If passive euthanasia would be right in this case then the continued existence of the patient in a state of great pain must be a greater evil than their death.
?So allowing the patient to continue to live in this state is a greater evil than causing their death.
?Causing their death swiftly is a lesser evil than allowing them to live in pain.
?Active euthanasia is a lesser evil than passive euthanasia.
But this still won't satisfy some people. James Rachels has offered some other arguments that work differently.
Do as you would be done by
The rule that we should treat other people as we would like them to treat us also seems to support euthanasia, if we would want to be put out of our misery if we were in A's position. But this isn't necessarily so:
? A person might well not want to be killed even in this situation, if their beliefs or opinions were not against active euthanasia.
?There are many examples of people who have accepted appalling pain for their beliefs.
Only rules that apply to everyone can be accepted
One well-known ethical principle says that we should only be guided by moral principles that we would accept should be followed by everyone.
If we accept that active euthanasia is wrong, then we accept as a universal rule that people should be permitted to suffer severe pain before death if that is the consequence of their disease.
8. DNR - Do Not Resuscitate
DNRs are Do Not Resuscitate orders. A DNR order on a patient's file means that a doctor is not required to resuscitate a patient if their heart stops and is designed to prevent unnecessary suffering.
The usual circumstances in which it is appropriate not to resuscitate are:
?when it will not restart the heart or breathing
?when there is no benefit to the patient
?when the benefits are outweighed by the burdens
Although DNRs can be regarded as a form of passive euthanasia, they are not controversial unless they are abused, since they are intended to prevent patients
suffering pointlessly from the bad effects that resuscitation can cause: broken ribs, other fractures, ruptured spleen, brain damage.
Proper use of DNRs
Guidelines issued by the British Medical Association and the Royal College of Nursing say that DNR orders should only be issued after discussion with patients or their family.
Although it may be difficult to have discussions with patients and their relatives about whether to revive or not, doctors accept that this is no reason why discussions should not take place.
The most difficult cases for discussion are usually those involving patients who know they were going to die, are suffering a lot of pain, but who could live for several months.
Dr Robin Loveday, a consultant says, "that is the situation where you really need a lot of discussion with the patient and their relatives to help them make a decision as to whether, if they do suffer a cardiac arrest, it is appropriate to have another go to give them a few more months of life."
Guidelines
The UK medical profession has quite wide guidelines for circumstances in which a DNR may be issued:
?if a patient's condition is such that resuscitation is unlikely to succeed
?if a mentally competent patient has consistently stated or recorded the fact that he or she does not want to be resuscitated
?if there is advanced notice or a living will which says the patient does not want to be resuscitated
?if successful resuscitation would not be in the patient's best interest because it would lead to a poor quality of life
In the UK, NHS Trusts must ensure:
?an agreed resuscitation policy that respects patients' rights is in place
? a non-executive director is identified to oversee implementation of policy ?the policy is readily available to patients, families and carers
?the policy is put under audit and regularly monitored
Abuse of DNRs
The clear guidelines on DNRs had to be firmly restated in 2000, after a number of seemingly healthy patients discovered they had 'do not resuscitate' or DNR orders written in their medical notes without consultation with them or their relatives.
There was further concern when it emerged that junior doctors had sometimes made DNR decisions because senior doctors were unavailable.
67 year-old Jill Baker found she had had a DNR order written on her medical notes without her consent. "She was understandably distressed by this as no discussion had taken place with her or her next of kin," said a doctor.
BBC News 27 June, 2000
Age Concern warned that the UK's elderly feared they were at risk of not being revived simply because of their age.
Arguing that DNRs might be a form of ageism in the NHS, a spokeseman said "Age Concern will not rest until the 'writing off' of patients' lives on the basis of their age has been stamped out."
9. The doctrine of double effect
This doctrine says that if doing something morally good has a morally bad
side-effect it's ethically OK to do it providing the bad side-effect wasn't intended. This is true even if you foresaw that the bad effect would probably happen.
The principle is used to justify the case where a doctor gives drugs to a patient to relieve distressing symptoms even though he knows doing this may shorten the patient's life.
This is because the doctor is not aiming directly at killing the patient - the bad result of the patient's death is a side-effect of the good result of reducing the patient's pain.
Many doctors use this doctrine to justify the use of high doses of drugs such as morphine for the purpose of relieving suffering in terminally-ill patients even though they know the drugs are likely to cause the patient to die sooner.
Factors involved in the doctrine of double effect
?The good result must be achieved independently of the bad one: For the doctrine to apply, the bad result must not be the means of achieving the good one. So if the only way the drug relieves the patient's pain is by killing him, the doctrine of double effect doesn't apply.
?The action must be proportional to the cause: If I give a patient a dose of drugs so large that it is certain to kill them, and that is also far greater than the dose needed to control their pain, I can't use the Doctrine of Double Effect to say that what I did was right.
?The action must be appropriate (a): I also have to give the patient the right medicine. If I give the patient a fatal dose of pain-killing drugs, it's no use
saying that my intention was to relieve their symptoms of vomiting if the drug doesn't have any effect on vomiting.
?The action must be appropriate (b): I also have to give the patient the right medicine for their symptoms. If I give the patient a fatal dose of pain-killing drugs, it's no use saying that my intention was to relieve their symptoms of pain if the patient wasn't suffering from pain but from breathlessness.
?The patient must be in a terminal condition: If I give the patient a fatal dose of pain-killing drugs and they would have recovered from their disease or injury if I hadn't given them the drugs, it's no use saying that my intention was to relieve their pain. And that applies even if there was no other way of controlling their pain.
Problems with the doctrine of double effect
Some philosophers think this argument is too clever for its own good.
?We are responsible for all the anticipated consequences of our actions: If we can foresee the two effects of our action we have to take the moral responsibility for both effects - we can't get out of trouble by deciding to intend only the effect that suits us.
?Intention is irrelevant: Some people take the view that it's sloppy morality to decide the rightness or wrongness of an act by looking at the intention of the doctor. They think that some acts are objectively right or wrong, and that the intention of the person who does them is irrelevant. But most legal systems regard the intention of a person as a vital element in deciding whether they have committed a crime, and how serious a crime, in cases of causing death.
?Death is not always bad - so double effect is irrelevant: Other philosophers say that the Doctrine of Double Effect assumes that we think that death is always bad. They say that if continued life holds nothing for the patient but the negative things of pain and suffering, then death is a good thing, and we don't need to use the doctrine of double effect.
?Double effect can produce an unexpected moral result: If you do think that a quicker death is better than a slower one then the Doctrine of Double Effect shows that a doctor who intended to kill the patient is morally superior to a doctor who merely intended to relieve pain.
The Sulmasy test
Daniel P. Sulmasy has put forward a way for a doctor to check what their intention really is. The doctor should ask himself, "If the patient were not to die after my actions, would I feel that I had failed to accomplish what I had set out to do?"
10. Is there a duty to die?
Is there a duty to die?
It sounds an odd question - most of us would say 'no', except perhaps for military and similar personnel in certain circumstances.
After all, when we say someone did their duty when they gave up their life to save others, we often mean that they did an act of heroism, well beyond the call of duty.
But some cultures, and some modern thinkers, think that there is a duty on a person to die in certain circumstances.
The ideas of John Hardwig
The philosopher John Hardwig re-opened this debate with an article in 1997. He says that an individual is not the only person who will be affected by decisions over whether they live or die. So, when deciding whether to live or die, a person should not consider only themselves; they should also consider their family and the people who love them.
What produces a duty to die?
Hardwig thinks that we may have a duty to die when the burden of caring for us seriously compromises the lives of those who love us:
?they may be physically exhausted by caring for us
?they may be emotionally exhausted by caring for us
?they may be financially destroyed by the cost of our healthcare
?they may be financially destroyed by having to give up work to care for us ?their home may become a place of grief and sickness
?other family members may be neglected as all attention is focussed on us
Hardwig says that there are no general rules - each case will be different, and he openly admits
I can readily imagine that, through cowardice, rationalisation, or failure of resolve, I will fail in this obligation to protect my loved ones. If so, I think I would need to be excused or forgiven for what I did.
John Hardwig
Nor does Hardwig think that a person should make their final decision without consulting their family - although he points out the difficulties in doing this.
What makes a duty to die more likely?
He goes on to list various features of a person's situation that make it more likely that they have a duty to die:
? a duty to die is more likely when continuing to live will impose significant burdens on our family and loved ones