Euthanasia

Of all the complicated issues facing health care workers; one of the most controversial may be euthanasia. There can be no doubt that advances in medicine have led to significant progress in prolonging life; but this has resulted, surprisingly, in new issues regarding quality of life, and passionate debates about euthanasia. The term ‘euthanasia’ can trace its origins to the Greeks. In their estimation it was synonymous with the phrase ‘good death’. 

Today euthanasia is recognized as ‘the act or practice of ending the life of a person; most regularly by lethal injection or the suspension of medical treatment’. However, agreeing on the meaning of a word is in no way indicative of accordance of the philosophical underpinnings of such. In light of the natural human inclination to “view that human life has special value; there is no serious ethical theory that allows for the killing of people without strong moral justification” (Kuhse & Singer 2006). Therein lies the essence of the euthanasia dispute.

Nowhere is this more evident than in the compendium edited by Helga Kuhse and Peter Singer entitled Bioethics: An Anthology. Certainly, the simplistic title belles the expansive contents addressing the complex and multi-faceted subject of medical ethics as told from the view of experts across the field. In a tome that extends well past 700 pages there is not an issue related to euthanasia and bioethics that is not given a fascinating ‘once over’; prodding the reader to grapple with this topic before accepting the responsibility of a health care professional; and provoking the realization of the ethical and moral obligations that accompany employment in the health care field. According to one reviewer “professionals and scholars will find that the Anthology is deep and broad; providing a very helpful pedagogical tool for those involved in all aspects of health care ethics” (McGill 2008). More than ever, upon completion of this text there is a recognition that this profession requires more than a basic understanding of the general principles of health care.  

Many believe there are only two distinct views of euthanasia. Either one supports euthanasia as an act of mercy; in which a person’s suffering may be ended; or one opposes it; often on the basis of religion but perhaps only from a personal perception of the sanctity of life. However, this is far from true for in many instances’ euthanasia is not a purposeful decision but may fall somewhere along a ‘pro’ and ‘con’ continuum that considers a breadth of factors such as age, debilitation, availability of resources and; unfortunately; cost.  Too, euthanasia may not be simply the act of relieving pain and suffering but may be the decision to refrain from exercising "heroic" measures in an end-of-life situation. Frankly, each case is individual and personal; but there are four principles on which the debate usually rests; that of autonomy, non-maleficence, beneficence, and justice. For the purposes of this essay we will consider each of these separately. 

Patient autonomy is defined as the right of patients to make decisions about their medical care without their health care provider trying to influence the decision. Patient autonomy does allow for health care providers to educate the patient; but does not allow the health care provider to make the decision for the patient. It is incumbent upon the health care professional to provide a patient with all of the information he or she will need to make an informed decision about their own treatment – or in concert with their loved ones. However, a plethora of research studies have been conducted (and continue so) concerning patient autonomy and while findings from multiple sources are worth noting; only one will be considered.

According to one study in particular we learn that patient autonomy may be of greater concern to some ethnicities and to a greater degree than others. “A two-year, multidisciplinary study was conducted on attitudes about end-of-life decision making among elderly individuals in four ethnic groups (African American, European American, Korean American, and Mexican American). On a quantitative survey, Korean Americans reported negative attitudes about the use of life-sustaining technology for themselves but positive attitudes about its use in general” (Frank, Blackhall, Michel et al. 2008). Perhaps more germane to this study is the fact that it is an excellent example of the complexity of a singular issue related to euthanasia.

Non-maleficence is the warning, "Never do harm to anyone." On a case-by-case basis, the health care worker must evaluate whether any particular treatment or procedure is clinically indicated, and whether the procedure will provide benefit or undue burden to the patient. When considering a medical treatment for a patient, one speaks of ordinary and proportionate care versus extraordinary and disproportionate care. The reference point is always the patient. Now, of all issues surrounding bioethics this would seem to be the simplest for the health care worker to adhere to; the greatest good should and must be accomplished through any public health action. But often there are additional factors ‘at play’ that impact this expectation. One finds that the combination of non-maleficence and euthanasia results in the coined term ‘slippery slope’; and in the context of attitudes it often correlates to considerations of age, disease, and even the religious persuasion of the patient. 

The term beneficence connotes acts of mercy, kindness, and charity, and is suggestive of altruism, love, humanity, and promoting the good of others. It is understood in ethical theory to include all forms of action intended to benefit or promote the good of other persons including a patient. Regarding the patient, beneficence refers to the traditional role of the health care worker as the ‘Good Samaritan’. The compassionate health care worker performs acts of charity, kindness, and mercy; comes to the aid of the injured, the sick, and the dying; and relieves suffering. Natural or comfort care, the offering of food and water and the maintenance of body temperature and cleanliness for the dying elderly patient are all forms beneficence.

Justice means respecting the rights and dignity of each human being. The real purpose of civil law is to guarantee an ordered social coexistence in true justice, so that all may "lead a quiet and peaceable life”. In light of this the health care worker must be fair to his or her patient, respect their rights as a person; always giving the patient proper access to health care. Today the principles of social justice often impact upon health care as well.

Even now, however, other medical matters must also be brought to bear when euthanasia is considered including confidentiality, truth telling, and informed consent as well as the difference between ‘killing’ someone or ‘letting him or her die’; and, finally, the duties and obligations of health-care professional regarding euthanasia. Confidentiality means to hold private and it is incumbent upon the health care professional to respect this edict. 

Honoring patient privacy may help to prevent such issues as discrimination based on medical conditions. Also, if patients are confident that their privacy is protected, they are more likely to seek medical care as well as be more likely to discuss their problems candidly. Perhaps one of the greatest challenges of health care work is balancing the obligation of the privacy of a minor with the family’s legal right to know. The best advice is to be thoroughly knowledgeable about the laws and regulations in the jurisdiction in which you practice with regard to the confidentiality rights of adolescent patients.

It is futile to deny that “sometimes health professionals (HPs) express discomfort at having to broach the topic of prognosis, including limited life expectancy, and may withhold information or not disclose prognosis” (Hancock. Clayton, Parker, Wal der et al. 2007). In a comprehensive review of the literature that incorporated the findings of 46 studies relating to truth-telling the findings revealed two things. First, the majority of HPs believe that patients and caregivers should be told the truth about the prognosis. Second, in practice and authentic situations many simply either avoid discussing the topic or withhold the information altogether! The reasons for this oversight on behalf of the health care worker are many; but the results are often the same – devastating to a patient when the truth of their impending death becomes a reality; and a sense of betrayal by the HP for their cowardice.

From a strictly utilitarian standpoint; the question of truth telling becomes one of fairness versus that of autonomy in which it is the patient’s right to be informed of all the facts in order to maintain control over the healthcare decision-making process. One cannot deny that often by informing the patient of their condition the risk lies in destroying the quality of what remains of that individual’s life - as well as that of loved ones. .From a personal viewpoint there is no ethical argument strong enough that favors the failure to inform the patient of their condition; yet the literature is filled with arguments against that very stance. In these cases, collaboration, mentoring and deference to the institution’s expectations must all be weighed in the decision.

Is there a difference between ‘killing’ someone or ‘letting them die’? If one were to examine the literature, it would be facile to confirm this query precipitates passionate viewpoints from all sides – an issue rife with challenges to the ethical theorist. The heart of the debate may be identified in the distinction between “acts and omissions and killing and letting die. These distinctions are required by opponents of euthanasia to justify allowing some cases of passive euthanasia while forbidding all cases of active euthanasia” (Snelling 2004). But as one attempts to undertake an analysis of the underlying morality of euthanasia, we discover that the ethical status may be based upon an “absolute deontological position against deliberate killing, which cannot be overridden by appeals to favorable consequences” (Snelling 2004).  In the researcher’s estimation (as well as this writer’s) passive euthanasia can be allowed and it is possible to delineate among the concepts of acts and omissions, killing and letting die, and ordinary and extraordinary means. But that declaration alone; as well as the singular reference that supports one position over another; does not a valid argument make. Rather it is meant to provoke thinking and affirm that this question requires a thesis as a proper response (as do all the issues of this assignment). 

Our final consideration in this essay is the rights and responsibilities of the health care worker with regard to euthanasia. Any discussion of such should be prefaced with a reminder that first and foremost patient respect and autonomy are a prerequisite to practicing in the field. One’s professional demeanor must always be beyond reproach in all of our interactions with colleagues, allocation of resources and insurance providers.  In the end, the medical professional can advise but must respect the wishes of the patient and loved ones; whether or not he or she personally agrees or not.

While undertaking to complete this task, and considering the many aspects of euthanasia and bioethics, the opportunity to ruminate over these issues of import resulted in my renewed faith in the nobility of health care work. Contemplating the matters of life and death; from abortion to allocation of resources and more; instills recognition of the value of this work and its immediate impact on humanity. In the end, it refreshes one’s understanding of the term ‘life and death’ decisions; and in the judgment of this writer underscores the importance of grace and humility in the application of medical relief. While it may be difficult to remain neutral in the application of our healthcare knowledge; we are reminded that we have not been assigned the role of the ‘creator’ in the ultimate decision of the value of a single life. As health care workers we take an oath that all but forbids us to pass judgment but only to use of abilities in the service and care of any individual in need of our skills. 

References

Frank G.; Blackhall L.; Michel V.; Murphy S.; Azen S.; Park, K. (2008) A Discourse of Relationships in Bioethics: Patient Autonomy and End-of-Life Decision Making among Elderly Korean Americans. Medical Anthropology Quarterly; 12(4); pp. 403–423.

Hancock, S.; Clayton, J.;  Parker, S.; Wal der, S.; Butow, P.; Carrick, S. (2007). Truth-telling in discussing prognosis in advanced life-limiting illnesses: a systematic review. Palliative Medicine; 21(6);  507-516. 

Kuhse, H.; Singer, P. (2006). Bioethics: An Anthology. Oxford, Blackwell Publishing; 738 pp.

McGill, G. (2008). Bioethics: A Systematic Approach. By Bernard Gert, Charles M. Culver, K. Danner Clouser Bioethic: An Anthology. 2nd edition. By Helga Kuhse and Peter Singer, eds. Worth and Welfare in the Controversy over Abortion. By Christopher Miles Cooper. The Heythrop Journal; 49(3); pp. 507–510. 

Snelling. N. (2004). Consequences count: against absolutism at the end of life. Journal of  Advanced Nursing; May; 46(4): 350-7.