February 1981 II/6
ALLOWING A PERSON TO DIE
One serious problem in medical ethics arises in many different settings. In the neonatal nursery, the oncology ward, the surgical intensive care unit, in a long term care facility, or in a private home, health care professionals often must decide "when can we allow a person to die?"
When is it moral or ethical to stop prolonging life and merely allow a person, whether old or young, to die? There are two situations when this is allowable: one, when the treatment to prolong life would be useless and, the other, when prolonging life would cause a serious burden for the patient. Useless treatment is any treatment which does not benefit the patient. For example, a patient near death from kidney failure need not be treated with antibiotics if he contracts pneumonia because there is no surety that such treatment would prolong life for any significant time. Moreover, when death is imminent and the patient is clearly in irreversible coma, aggressive efforts to prolong life would be useless because longer life would not benefit the patient.
Determining when medical treatment or therapy would be a serious burden to a patient is a different matter. When we judge a treatment to he useless, we assume that death is imminent and that the treatment will not prolong life for any significant time. But we can envision many situations in which life could be prolonged through medical treatment, but either the treatment or the results of the treatment might cause a serious burden for the patient. Consider, for example, a patient with brain cancer: surgery to remove the growth is possible but, even if successful, there is a possibility of partial paralysis and blindness. One could refuse such life prolonging treatment because of the serious burden that might result. The decisive factor here is not the benefit of prolonged life which might result from the surgery, but the burden the treatment itself might impose upon the person. Such a refusal of treatment is not the equivalent of suicide. On the contrary it should be considered as an acceptance of the human condition, or a wish to avoid the application of a mechanical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community.
The Application of Principles
In order to determine in an ethical and compassionate manner whether treatment is useless or involves a grave burden, other factors must be considered:
1. The reason we can judge ethically that prolonging life is useless or would involve a serious burden is because human life is not the ultimate good, not the greatest value. Merely maintaining life, especially at the biological level is not the purpose of human life. Life, health, and all temporal goods are subordinated to the purpose of life. People may differ in defining the purpose of life: some may define it as sapient life, others as the potential for inter-personal relationships, and others as spiritual growth and development. But all seem to agree that when the purpose of life cannot be achieved, then the duty to prolong life is no longer present.
2. The basis for the patient-physician relationship is a promise by the physician to do what is best for the patient. Usually this means that the physician and other members of the health care team try to promote health and prolong life. Indeed, this is the specific purpose of the health care profession. Only in very exceptional cases then will the decision to allow a person to die be ethically justified. This decision must be made carefully and for each individual person. Thus no class of people, with certain specified symptoms, can be classified a priori as not suitable for life prolonging care.
3. In such an important decision, the patient should not only be consulted right also follows from the nature of the patient-physician relationship. Often, however, the person about whom the decision must be made is not conscious, either because of temporary or permanent brain damage or undeveloped psychic capacity. In these cases, the family, with the advice of the ·medical/pastoral team, have the right to make the final decision provided they are seeking the good of the patient. In forming this decision, family members should include financial concerns and other important factors that a prudent person would consider. But family members must be careful not to put their self-interest before that of the patient. If medical personnel believe firmly that the rights of the patient are being violated, they should express their concern even through an appeal to civil authority. suited but given the right to make the final decision. from the nature of the patient-physician relationship.
4. There is a great difference between allowing a person to die and putting a person to death. One who understands this distinction would not allow an otherwise healthy person to die simply because the person could not feed himself. Determining that a retarded child with duodenal atresia should starve to death, for example, is not a justifiable decision. The surgery to correct the atresia and thus prolong life should be performed because it cannot be shown that such treatment is useless nor that life for a retarded person is a serious burden.
5. In doubt whether the treatment would be useless or would cause a serious burden, the patient should be given the benefit of the doubt and life should be prolonged. Often the uncertainty will result from the lack of clear medical diagnosis and/or prognosis. Those who work with the newborn offer many examples of children who were of doubtful life expectancy when they were newborn but who received aggressive care and made stunning progress.
6. Even though aggressive efforts to prolong life may be foregone because it would either be useless or involve a serious burden, the care that will mitigate suffering must be offered. Hence, patients should be bathed, be given food and water, and have their serious pain alleviated even if the medication might indirectly shorten life.
Allowing oneself or another to die is a very serious ethical decision. The foregoing principles based upon the purpose of human life and the physician-patient relationship, will not make such decisions easy. But they do offer direction toward solutions which enable the health care person to be aware that he/she is striving for "what is best for the patient."
Kevin O'Rourke, OP
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