2011Marek Vácha

René Descartes

...that we could be free of an infinitude of maladies both of body and mind, and even also possibly of the infirmities of age, if we had sufficient knowledge of their causes, and of all remedies with which nature has provided us.

René Descrates: Discourse on Method, Part VI.)

Four Principles of Medical Ethics

Nonmaleficence Beneficence Autonomy Justice

Advance Care Planning

= process whereby a patient, in consultation with healthcare providers, family members, and important others, makes decisions about his or her future healthcare

„Every human being of adult years and sound mind has the right to determine what shall be done with his own body.“ (Benjamin Cardozzo´s statement, 1914)

USA

state laws allow individuals to complete advance directives documents and to name healthcare decision makers

federal law requires all patients admitted to hospital to be notified of this right

most european countries have followed suit with provisions for advance care planning

Health Care Proxy

in association with passage of the Patient Self-Determination Act (1990) laws has been passed that enable individuals to designate the person they wish to make healthcare decisions for them once they lose decision-making capacity

in addition, laws pertaining to informed consent have given family members the right to make decisions on behalf of incapacitated patients

an alternative to family-based substitute decision making is using the courts, such as assigning a court-appointed guardian. This mechanism exists in both USA and Canada

Decision MakersUSA

if no healthcare agent is authorized and available, the practitioner must make a reasonable inquiry as to the availability of other possible surrogates according to the order of priority legal guardian spouse adult child parent sibling grandparent grandchild close friend

(Veterans Health Administration, 2003)

Decision Makers

when patients are asked who they would want to represent them, the majority opt for their own family members

(Singer, P.A., Viens, A.M., (eds.) (2008) The Cambridge Textbook of Bioethics. Cambridge University Press, p.60)

Patients at increased risk for losing decision-making capacity

These high risk situation include: early dementia history of stroke health conditions that predispose to a future stroke

(e.g. uncontrolled hypertension) health conditions that predispose to delirium (e.g.

frailty, advanced age) terminal illness recurrent severe psychiatric illnesses (e.g. severe

dementia, mania, psychosis) families with conflicts social isolation (e.g. no family members or close

friends)

Health Care Proxy

= a substitute decision maker the criteria on which the decision should

be based are: the specific wishes previously expressed by

the patient if specific wishes are not known, the patient´s

known values and beliefs if neither specific wishes or values and beliefs

are known, the patient´s best interests

Problems

advance care planning has not been as successful as proponents would wish some patients change their views as time

passes others request life-prolonging interventions

that subsequently prove to be unrealistic substitute decision makers are not always

sure that a patient´s situation is equivalent to that described in an advance directive

Substituted judgement and best interests

Substituted judgements liwing will, advanced directives without an advance directive, a proxy may then refer to

the patient´s values, both implicit and explicit, regarding worldview (including religious beliefs), lifestyle, and health care.

Best interests in many cases, a proxy may not have any information a

bout a paataient´s values (infant, young children, mentally disabled adults)

health is preferable to ilness, and life is preferable to death

A twenty-eight-year-old man decided to terminate chronic renal dialysis because of his restricted lifestyle and the burdens on his family. He had diabetes, was legally blind and could not walk because of progressive neuropathy. His wife and physician agreed to provide medication to relieve his pain and further agreed not to put him back on dialysis even if he requested this action under the influence of pain or other bodily changes. (Increased amounts of urea in the blood which restlt from kidney failure, can sometimes lead to altered mental states, for example). While dying in the hospital, the patient awoke complaining of pain and asked to be put back on dialysis. The patient´s wife and physician decided to act on the patient´s earlier request not to intervence, and he died four hours later.

Beauchamp, T.L., Childress, J.F., (2009) Principles of Biomedical Ethics. 6th ed. Oxford University Press, Oxford and New York, p. 110

World Medical Association Declaration on the Rights of the Patient Adopted by the 34th World Medical Assembly, Lisbon, Portugal,1981

The unconscious patient

If the patient is unconscious or otherwise unable to express his/her will, informed consent must be obtained whenever possible, from a legally entitled representative.

If a legally entitled representative is not available, but a medical intervention is urgently needed, consent of the patient may be presumed, unless it is obvious and beyond any doubt on the basis of the patient's previous firm expression or conviction that he/she would refuse consent to the intervention in that situation.

However, physicians should always try to save the life of a patient unconscious due to a suicide attempt.

Persistent Vegetative State (PVS) = a clinical condition of unawareness of

self and environment in which the patient breathes spontaneously, has a stable circulation, and shows cycles of eye closure and opening which may simulate sleep and waking

the vegetative state has to have endured for at least one month in order for it to be considered persistent The Multi-Society Task Force on PVS,

"Medical Aspects of the Persistent Vegetative State," New England Journal of Medicine 330 (1994)

Nancy Cruzan

Karen Ann Quinlan(1954 – 1985)

Donald Dax Cowart

In 1973, Donald Cowart was critically injured in a propane gas explosion, that caused severe burns over sixty-five percent of his body.

For more than a year, he objected to the painful treatments that he was receiving. Cowart was physically incapable of ending his own life, since his hands had been severely damaged in the accident, but he made repeated verbal requests that he be allowed to die, or that someone help him end his own life.

Donald Dax Cowart

Despite his protestation, his doctors and his mother continued to provide treatment, including a number of paonful skin graft surgeries.

Cowart survived the ordeal and is still alive today, but insists that hed should have been allowed to die.

(Pierce, J., Randels, G., (2010) Contemporary Bioethics. A Reader With Cases. Oxford University Press, Oxford and New York, p. 115)

Baby K.(1992 – 1995)

Terry Schiavo3/12 1963 – 31/03 2005

Terry Schiavo03/121963 – 31/032005

Eluana Englaro1972 - 2009

in a persistent vegetative state since being injured in a car crash in 1992.

In July 2008, a court in Milan ruled that doctors had proved Ms Englaro's coma was irreversible.

It also accepted that, before the accident, she had expressed a preference for dying over being kept alive artificially.

Eluana Englaro1972 - 2009

Eluana Englaro, the comatose woman at the centre of a euthanasia debate that divided Italy and sparked a constitutional crisis, died on Feb 9 2009 at the age of 38, four days after doctors began to remove her life support.

She had been in a vegetative state for 17 years after a car accident. Ms Englaro’s father had been fighting for a decade for a dignified end to his daughter’s life in accordance with what he and her friends have testified were her own wishes. At his request, doctors at a clinic in Udine stopped feeding.

Eluana Englaro1972 - 2009

Italy's Prime Minister Silvio Berlusconi drafted a decree to prevent doctors from letting her die, but President Giorgio Napolitano refused to sign it.

Italy does not allow euthanasia. Patients have a right to refuse treatment, but they are not allowed to give advance directions on the treatment they wish to receive if they become unconscious.

Trace of Thought Is Found in ‘Vegetative’ Patient

Dobrovolník či pacient má myslet na pohybovou aktivitu (hraní tenisu), když chce říci „ano“ a má se uvolnit nebo myslet na prostorovou aktivitu (procházení se po ulicích), chce-li říci „ne“

Trace of Thought Is Found in ‘Vegetative’ Patient A two-way channel to an immobilized, severely

brain-injured person also opens up a world of ethical challenges.

“If you ask a patient whether he or she wants to live or die, and the answer is die, would you be convinced that that answer was sufficient?” said Dr. Joseph J. Fins, chief of the medical ethics division at Weill Cornell Medical College in New York. “We don’t know that.

Their answer might be ‘Yes, but’ — and we haven’t given them the opportunity to say the ‘but.’

http://www.nytimes.com/2010/02/04/health/04brain.html?ref=health

Futile Treatment

quantitative futility a treatment is capable of producing a result,

but extremely unlikely to do so recovery is "impossible" or "virtually

impossible"

qualitative futility the problem lies not in the low probabilities,

but when there are questions about the value of the end result ("lacking in purpose")

"Good"

how much longer life is an unqualified good for an individual?

how much more life is good for us as individuals, other things being equal? the simple answer is that no limit should be set. life is good, death is bad

some, of course, eschew any desire for longer life they profess still more modest claim:

not adding years to life, but life to years no increased life span, but only increased health

The problem of boredom and tedium

if the life span were increased - say by twenty years - would the pleasures of life increase proportionately? would professional tennis players really enjoy

playing 25 percent more games of tennis? would the Don Juans of our world feel better

for having seduced 1 250 women rather than 1000?

The problem of boredom and tediumLeon Kass

To know and to feel that one goes around only once, and that the deadline is not out of sight, is for many people the necessary slur to the pursuit of somenting worthwhile. To number our days is the condition for making them count and for treasuring and appreciating all that life brings

The problem of boredom and tediumLeon Kass

Homer´s immortals, for all their eternal beauty and youthfulness, live shallow and rather frivolous lives, their passions only transiently engaged, in first this and then that.

they live as spectators of the mortals, who by comparison have depth, aspiration, genuine feeling, and hence a real centre to their lives.

Kass, L.R., (1983) The Case for Mortality. The American Scholar 52, no.2:173-191 in Pierce, J., Randels, G., (2010) Contemporary Bioethics. Oxford University Press, NY, Oxford. p. 147-154)

The problem of boredom and tediumLeon Kass

Homer´s immortals, for all their eternal beauty and youthfulness, live shallow and rather frivolous lives, their passions only transiently engaged, in first this and then that.

they live as spectators of the mortals, who by comparison have depth, aspiration, genuine feeling, and hence a real centre to their lives.

Kass, L.R., (1983) The Case for Mortality. The American Scholar 52, no.2:173-191 in Pierce, J., Randels, G., (2010) Contemporary Bioethics. Oxford University Press, NY, Oxford. p. 147-154)

The problem of boredom and tediumLeon Kass

It is probably no accident that it is a generation whose intelligentsia proclaim the meaninglessness of life that embarks on its indefinite prologation and that seeks to cure the emptiness of life by extending it.