End-of-Life Care Competent and Incompetent Patients Important Concepts People, and Cases Futility Death (definitions) Competence Advance directives Living will Designated Power of attorney Kevorkian, Quill, Quinlan, Cruzan Might There be a Duty to Die? Some have argued for it See Hardwig essay available via ERes Emphasis on role of the family rather than just individual Physician duty (another Hardwig essay) is to decide based on interests of family, not individual. EB: We can respect a patient s freely chosen obligation without imposing it. Hardwig slides Medical Ethics 1
Technology and Ethics On many issues, big divide between those who embrace technology as cure and those who are cautious and fear its results. Technology doesn t answer ethical questions, but it raises new ones. Most obvious: cloning, stem cells, genetic engineering, etc. Also true of euthanasia: we can keep people alive who would have died years ago. Question gets raised: to what lengths should we go to extend life? When is life not worth extending? Can We End Life Earlier Without Euthanasia? If treatment is futile. If patient can be pronounced dead; i.e., if we change the definition of death so that it includes patients previously considered alive. Concept of Futility Controversy over meaning of futility. Physiological futility: impossible to perform the procedure (e.g., feeding tube cannot be inserted or nutrition cannot be absorbed even with it.) Futility in terms of survival or conscious life Futility in terms of survival with a meaningful conscious life. Argument: should not be used if real issue is quality of life or wise use of scarce resources Medical Ethics 2
Concept of Death Older, traditional view: death defined cessation of heartbeat, breathing. Now: brain death ( whole brain death ) Definition of death is an ethical issue, not a purely medical one. Why? Some want to go further: higher brain death Persistent vegetative state ( PVS ) and anencephalic infants are not dead. Arguments in favor of Voluntary Active Euthanasia It relieves unnecessary suffering It allows the exercise of a competent patient s autonomy (freedom, self-determination) It is not morally different from what we appropriately permit now (withdrawal of lifesustaining treatment) It saves resources better used elsewhere Arguments Against Voluntary Active Euthanasia There is a fundamental moral difference between acting with an inten to kill and not providing lifesustaining treatment and Killing innocent people is always wrong. It goes against the human natural tendency to live. (Gay-Williams) It will lead doctors (slippery slope) not to work as hard to preserve life (consequentialist) It contradicts the purpose of the medical profession (nonconsequentialist) Such a policy will put pressure on patients to choose to die even when they want to live. Medical Ethics 3
What If Patient is Not Competent? Two key obligations Respect freedom (autonomy) of competent patients to control their own medical care* Protect incompetent and vulnerable patients from the consequences of their own harmful choices. *What s so important about autonomy? Autonomy as Crowning Concept of Bioethics Debatable, but basic to bioethical thinking. Why? Every medical decision has a factual and an ethical component. Doctors (and other caregivers) are experts in medicine, but not in ethics. Value dimension of decision should be based on patient s values, not doctors. Ethical decisions should not differ from physician to physician but from patient to patient. What Is Required for Competence? Rationality? Must mean capacity, not current decision being rational in caregiver s mind Standard: ability to understanding consequences of action Authenticity : choice consistent with previous values (may be idiosyncratic and seemingly irrational, but own s own) But transforming experiences in life often change values Marriage, child-rearing, religious conversion, one s own illness Medical Ethics 4
The Case of Ethan Zinker Decision Scenario 1 (p. 242) 92, dementia, pneumonia Had been professor of physics, Columbia U. Advance directive clear: if failing mentally, does not want continued treatment Pneumonia could easily be treated with antibiotics He seems to enjoy his current life Should he be treated with antibiotics to extend his life? Should Autonomy Extend to Incompetent? Arguments in Favor The next logical step in respecting autonomy Not only should doctor not decide, but decision should be guided by patient s own values Ask: what would patient want if he/she were competent. Should Autonomy Extend to Incompetent? Arguments Against Choices from past often conflict with present interests Past patient cannot know what future self would want. (Is it a different self?) Would lead to death (nontreatment) of patients who have interest in continued life Other issues (cost, burden on family) often not confront directly on their own terms Medical Ethics 5