Medical Decisions at the End of Life (Biomedical Ethics)

Charles Lohman

Defining Death

• Until the second half of the twentieth century, DEATH was when a person stopped breathing and their heart stopped beating.– BUT the definition of DEATH shifted focus from

the lungs and heart to the BRAIN with the introduction of the mechanical ventilator in the late 1960s and early 1970s.• The mechanical ventilator made it possible for a

person’s lungs and heart to function when they could no longer.

Whole Brain Criterion of Death

• The whole brain criterion of DEATH has been widely accepted by the general public and adopted in legal and clinical practice.– The whole brain criterion of DEATH is when all

BRAIN functions, including those of the cerebral cortex and brain stem, have permanently ceased.• Why?

– BECAUSE these functions are necessary for the integrated functioning of the organism as a whole.

Whole Brain Criterion of Death1 of 2 Challenges

• 1.) The whole BRAIN criterion suggests that the BRAIN controls and integrates all bodily processes.

• BUT the whole BRAIN criterion is physiologically inaccurate.– The BRAIN does not control nor integrate all bodily processes.

» FOR EXAMPLE, although the BRAIN mediates breathing and nutrition, these bodily functions are not reducible to or completely controlled by the activity of the BRAIN.

» Some of the body’s integrated functions can continue for some time after the BRAIN has ceased to function.

Whole Brain Criterion of Death2 of 2 Challenges

• 2.)DEATH should be when the higher BRAIN necessary for CONSCIOUSNESS permanently ceases to function.

• DEATH should not be defined in terms of the whole BRAIN.– But should be defined in terms of the capacity for

CONSCIOUSNESS.» CONSCIOUSNESS depends on the activity of the cerebral

cortex so the permanent cessation of cortical function is sufficient for the DEATH of a person.

» So based on this definition a person may be DEAD although he/she is still breathing and his/her heart is still beating.

WITHDRAWING and WITHHOLDINGTreatment

• Both WITHDRAWING and WITHHOLDING life-sustaining treatment can lead to a patient’s DEATH. – So there does NOT ‘seem’ to be a MORALLY

significant difference between the WITHDRAWING and WITHHOLDING treatment.

– In other words, if one FORESEES that their actions or ‘non-action’ will ensure an OUTCOME, then one plays a causal role in the outcome by intentionally acting or by intentionally omitting to act.

It’s about the Patient’s Best Interest

• How ACTION and OMISSION benefit or harm the patient is what is MORALLY relevant.– What is NOT MORALLY relevant is WITHDRAWING

and WITHHOLDING treatment.• In other words, it’s about the patient’s best interest.

– For example, a doctor may be obligated to withdraw a treatment if it is clear that it offers no benefit to and only harms the patient.» If a treatment is not likely to reverse a condition, then

there is no duty to initiate it. Similarly, if an initiated treatment cannot reverse a condition, then there is no duty to continue it.

Double Effect

• Double Effect (DDE) specifies a moral distinction between INTENDING a harmful effect by acting, and FORESEEING a harmful effect as an unintended outcome of a good action.– In DDE, the distinction is between DIRECT AND

INDIRECT agency.• In other words, the distinction is between ‘what we do’

and ‘what we bring about’ as a result of what we do.

Double Effect’s Morality• With DDE, it is MORALLY permissible to give a

high dose of morphine to relieve a patient’s pain when a doctor FORESEES that it will hasten the patient’s death. BUT it is MORALLY impermissible to give morphine in order to bring about the patient’s death.– In other words, the doctor can NOT permissibly kill

the patient as an intended means to the end of relieving pain.• So, in short, with DDE, the death is a side effect of giving the

morphine.– Whereas it is not the doctors goal or reason for giving it so it is

not intended to kill the patient.

EuthanasiaPhysician-Assisted Suicide

• EUTHANASIA – death that benefits the person who dies.

• PHYSICIAN-ASSISTED SUICIDE (PAS) – the act that results in the death is performed by the patient, who is assisted by a physician or someone else who provides the means through which the patient can take his/her own life.

The 3 Types of EUTHANASIA

• Voluntary EUTHANASIA – involves a patient making a voluntary and persistent request that someone actively cause his/her death.

• Involuntary EUTHANASIA – involves killing a patient against his/her expressed wishes to the contrary, or without consulting such wishes.

• Nonvoluntary EUTHANASIA – involves someone killing a patient who is incompetent and unable to express his/her wishes about wanting to live or die.

PAS’s 6 Conditions• PAS’s 6 conditions to be morally permissible:

– 1.) There must be a diagnosis of terminal illness.– 2.) The patient must be suffering from an unbearable and

irreversible condition.– 3.) The patient must be informed about the diagnosis and

prognosis of his/her condition, as well as about alternatives to PAS, such as hospice care and other palliative services.

– 4.) The patient who requests PAS must not be suffering from treatable depression.

– 5.) The patient must make an enduring and voluntary request for assistance in dying.

– 6.) When a patient dies as a result of PAS, the doctors who assist him/her must report it to the regulatory authorities.