End-of-Life Care Competent and Incompetent Patients Important - - PDF document

End of Life Care, Euthanasia, and the Incompetent Medical Ethics 1

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

End of Life Care, Euthanasia, and the Incompetent Medical Ethics 2

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

End of Life Care, Euthanasia, and the Incompetent Medical Ethics 3

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 life- sustaining treatment)

► It saves resources better used elsewhere

Arguments Against Voluntary Active Euthanasia

► There is a fundamental moral difference between

acting with an intent to kill and not providing life- sustaining 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.

End of Life Care, Euthanasia, and the Incompetent Medical Ethics 4 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,

• ne’s own illness

End of Life Care, Euthanasia, and the Incompetent Medical Ethics 5

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