Here we consider two very different yet similar cases. Carole Jones is an elderly woman living in Edmonton, Canada where she’s suffered several cardiorespiratory arrests causing paralysis of her breathing muscles. The physicians have stated there is no possibility of restoring those muscles and she’s been in the ICU for several weeks in a semi-conscious state. Her son wants his mother to return to her homeland Jamaica before dying as their religious beliefs suggest her soul will be condemned if not on native soil. On the other hand, John is a 26 year-old man with “the elephant man’s disease” where non-malignant tumors attach themselves to the body’s nerves. He’s undergone over 100 surgeries in his life to remove tumors that lead to total deafness and partial blindness, almost complete paralysis, and total impairment of the breathing muscles. He is fully alert and conscious, deeming him competent and able to make rational choices. Both Carole and John are dependent on their respirators to prolong their lives, however Carole (and her Son) wants to remain on the respirator until she returns to her home while John is requesting that he be disconnected.
The first thing to consider in either case is whether or not anyone has the right to take someone off of life support or neglect to resuscitate him or her. If a patient has a pre-planned do not resuscitate (DNR) before experiencing whatever trauma brought them into the care of the physician, I say honor their longstanding request. In a case like Carole’s, and accepting the sanctity principle, I do not believe the physician has the right to override the son’s request and issue a DNR because that clearly goes against rules of patient autonomy. Although John’s situation may require a more morally daunting task for a physician, it’s a more reasonable circumstance because of his clear competent state and lengthy medical history that gives a detailed description of his quality of life. It does put the physician in a precarious situation because they have to directly intervene in order to fulfill the patient’s wishes in being disconnected from the respirator and end his life, no matter what the quality.
Either suggested situation ends in the ultimate death of the patient based on approval from a medical professional. But are we really dealing with the same decision in both cases? I say we are looking at two morally unique events because one is passive while the other requires direct action. Subscribing to Becker’s suggestion, issuing a DNR doesn’t cause death; it merely allows nature to take its course (Thomas, 213). It also should be noted that in practice, resuscitations aren’t as successful as we make them out to be, as only about 20 percent of older patients make it out of the hospital after suffering cardiac arrest (Graham, 1). Disconnecting the respirator is an intervention that should be approached with caution even when deemed appropriate because the decision made is irreversible and both parties are responsible for the an almost guaranteed death where as the physician cannot be held accountable for a DNR if previously arranged.
Braddock, James, “Do Not Resuscitate (DNAR) Orders” University of Washington School of Medicine
https://depts.washington.edu/bioethx/topics/dnr.html
Graham, Judith, “New Data to Consider in D.N.R. Decisions” The New York Times
Thomas, John, Well and Good
I enjoyed reading your blog post as I have been trying to understand the moral implications of passive versus active measures in regards to physician-assisted suicide and/or euthanasia. In this case, we cannot judge the physician’s actions as morally right or wrong solely based on whether the action is passive or active for a few reasons. First, passive action is still an active choice to refrain from acting. As stated by Dr. James Rachels, “It is not exactly correct to say that in passive euthanasia the doctor does nothing, for he does do one thing that is very important: he lets the patient die” (Rachels, 1975). For this reason, we cannot instantly give the physician who lets the patient die a moral golden star, so to speak. Instead, we must learn the facts of the case on an individual basis.
This brings me to the second reason these issues are not so black and white. The moral implications of the physician’s actions must be judged based on the case. I agree with your decisions in both cases. As you mention, the most important moral value that is of concern here is respecting patient autonomy. In Carole’s case, it would be morally wrong to file a DNR against her wishes despite the low likelihood that she will ever make it to Jamaica. In her case, the doctor should keep her on life-sustaining equipment.
However, in John’s case, it would be morally wrong to keep him on life-sustaining equipment. As discussed in the case, he is competent and sure of his decision. The doctor should respect his wishes. However, herein lies the question of how to let John pass away. Should the doctor remove him from the respirator and “passively” allow him to die due to oxygen asphyxiation? That does not seem like a pleasant way to die. Or should he speed up the process of death by prescribing sedatives or other drugs? According to the American Medical Association, “The principle of patient autonomy requires that physicians must respect the decision to forgo life-sustaining treatment of a patient who possesses decision-making capacity”; however, they also state that “physicians must not perform euthanasia or participate in assisted suicide” (AMA, 2006). Initially, I agreed with this statement; however, after reading the thoughts of Dr. Rachels, it may be more morally justified to actively help John die. He states, “If one simply withholds treatment, it may take the patient longer to die, and so he may suffer more than he would if more direct action were taken and a lethal injection given. The fact provides strong reason for thinking that, once the initial decision to not prolong his agony has been made active euthanasia is actually preferable to passive euthanasia” (Rachels, 1975). These cases are definitely challenging and controversial! I look forward to hearing what others think.
REFERENCES
Rachels, J. (1975). Active and Passive Euthanasia. The New England Journal of Medicine. http://euthanasia.procon.org/view.answers.php?questionID=000147
AMA. (2006). Decisions Near the End of Life. American Medical Association. http://euthanasia.procon.org/view.answers.php?questionID=000147
Hi Julia,
Thank you for reading my post and responding with your own thoughts! I agree that we need to examine the moral implications beyond this case in relation to the physician’s action (or inaction). Although, to me, the decision is clear in both cases that the decision of the competent patient should be considered first and foremost, it is more difficult to determine to what extent the physician can interfere, if at all. But does standard practice already inserting the physician into an active role in the decision? The American Hospital Association reported that about 70 percent of hospital deaths occur after a decision has been made to stop current treatment. The term “passive euthanasia” refers to the fact that regardless of who’s aware and informed, these deaths aren’t unplanned. There is a difference between preventing suffering and preventing death. Although some may believe death is the ultimate suffering, a once able bodied, healthy patient who is told they will be reduced to a life of continuous pain post-treatment, may disagree. Dr. Maurie Markman, a gynecological cancer specialist says “My intent always is to relieve suffering. If that’s my goal, I can look myself in the eye. I can go to sleep at night (Kolata, 1997). Many times giving a patient medicine to temporarily relieve their pain will shorten their life but they aren’t properly informed (Arlotta, 2015). I’m sure if this information were presented up front or in a different setting, many patients would feel they could handle the pain if it meant extending their life. So if this kind of “passive euthanasia” is considered morally sound and generally accepted by the medical community, I don’t understand why we see a case like John’s in such different light.
References:
Arlotta, CJ (2015) Antipsychotic Drugs Hasten Death in Dementia Patients. Forbes.
https://www.forbes.com/sites/cjarlotta/2015/03/19/antipsychotic-drugs-hasten-death-in-dementia-patients/#f45e3dc5e1b1
Kolata, Gina (1997) Passive Euthanasia in Hospitals Is The Norm, Doctors Say. The New York Times.
http://www.nytimes.com/1997/06/28/us/passive-euthanasia-in-hospitals-is-the-norm-doctors-say.html
I agree with the author for both decisions. In those situation, there are two perspectives to consider: one is from the physician’s perspective and one from the patient’s perspective. As we defend the patient’s autonomy, it is also important to be reminded that physician’s ability to assess what the patient’s current level of functional ability and cognitive status is. From the physician’s perspective, if the patient is cognitively intact and in reasonably good shape, it is essential for physicians to persuade patient (or patient’s family member) given their professional knowledge. But ultimately, physicians would need to respect the patient’s autonomy on his body.
Reference
Rachels, J. (1975). Active and Passive Euthanasia. The New England Journal of Medicine. http://euthanasia.procon.org/view.answers.php?questionID=000147
Braddock, James, “Do Not Resuscitate (DNAR) Orders” University of Washington School of Medicine
https://depts.washington.edu/bioethx/topics/dnr.html