Write a 2-3 page paper that examines the moral and ethical issues involved in making a decision regarding limiting life support.

End-of-Life Issues

With our framework of ethical theories and principles in hand, we begin our look at some of the critical ethical issues in our contemporary world, starting with end-of-life issues. This assessment covers ethical questions related to end-of-life care. Passive euthanasia is the removal or refusal of life-sustaining treatment. Examples of passive euthanasia include removal of a feeding tube or a ventilator, or forgoing a life-prolonging surgery. Passive euthanasia is legal in all 50 states, and the principle of autonomy gives informed patients the right to refuse any and all treatments. Patients who are unable to make such decisions in the moment (because they are unconscious, for example) might have made their intentions clear beforehand with an advance directive or similar document. Things become more complicated, however, when a patient who is unable to make treatment choices has not made his or her wishes clear, either formally in a written document, or informally in conversations with family members or friends. Another problem concerns cases in which there is disagreement about whether the treatment is sustaining the life of a person in the full sense or merely as a body that, because of severe and irreversible brain trauma, is no longer truly a living person.

Active euthanasia, or assisted suicide, introduces further difficult moral questions. A patient who has a terminal illness and who has refused treatments that would merely prolong a potentially very painful and debilitating death might want the process of dying to be hastened and made less painful. The patient might want to take his or her own life before the disease reaches its horrible final stages. Should patients be legally allowed to have help in this endeavor? If suicide itself is not morally wrong, at least in cases like these, is it wrong for another person to directly help bring about the patient’s death? Is it wrong for doctors, a role we naturally associate with healing and the promotion of life, to use their medical expertise to deliberately end a patient’s life if the patient wants this?

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

Competency 1: Articulate ethical issues in health care.

Articulate the moral issues associated with limiting life support.

Competency 2: Apply sound ethical thinking related to a health care issue.

Demonstrate sound ethical thinking and relevant ethical principles when considering limiting life support.

Explain important considerations that arise when contemplating limiting life support.

Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with health care professionals.

Exhibit proficiency in clear and effective academic writing skills.

Preparation

Case Study: Mr. Martinez.

This media piece provides the context for this assessment; make sure you have reviewed the case study thoroughly.

Additionally, it may be useful to think through the following issues as they relate to Mr. Martinez’s case:

Should Mr. Martinez be transferred to intensive care, where his respiratory failure can be treated by a ventilator, and by CPR if necessary, and his oxygen level can be monitored?

What are the key ethical issues or models at play in this case study?

What are the key end-of-life issues at play in this case study?

How can an understanding of models and best-practice help to guide health care practitioners to make ethical and legal decisions?

Instructions

In a 2–3 page analysis of the case study, address the following:

The patient’s directives.

The patient’s quality of life.

The family’s stated preferences.

The moral issues associated with limiting life support.

The ethical principles most relevant to reaching an ethically sound decision.

Important considerations such as implications, justifications, and any conflicts of interest that might arise because of the patient’s respiratory failure.

When writing your assessment submission assume that doctors cannot contact Mrs. Martinez and must make this choice on their own. To help you reach an objective, ethically sound decision, draw upon concepts and arguments from the suggested resources or your independent research. Support your response with clear, concise, and correct examples, weaving and citing the readings and media throughout your answer.

Submission Requirements

Written communication: Written communication is free of errors that detract from the overall message.

APA formatting: Resources and citations are formatted according to current APA style and formatting guidelines. Refer to Evidence and APA for guidance.

Length: 2–3 typed, double-spaced pages.

Font and font size: Times New Roman, 12 point.

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+This is the case study:

Ethics of End-Of-Life Issues

CASE ONE

“Joe contracts bilateral pneumonia. He is treated with antibiotics and put on a mechanical respirator. After a few weeks, the pneumonia improves and the physician starts to wean Joe from the respirator. Even with a gradual approach, the weaning fails and Joe demands to be put back on the respirator when he becomes terrified at being short of breath. The physician feels that the ultimate chances of weaning Joe are no more than 20 percent. Joe, 80 years old and accustomed to being in control, becomes discouraged and increasingly unable to bear the painful medical procedures (constant intravenous feedings, frequent needle punctures for arterial blood gases, suctioning, etc.) After three weeks of unsuccessful attempts, Joe refuses to cooperate. He asks that the respirator be disconnected. “I want to die,” he states. Despite the pain, Joe is alert and aware and is, in the opinion of the staff, fully competent. His wife and one son keep begging the physicians and nurses to do something to help Joe recover fully.” (Garrett, Baillie & Garrett, 2001, p. 194)

Consider These Questions

“Does Joe have a right to refuse treatment on the respirator? Do the physician and the nurses have a right or duty to help Joe psychologically and pharmacologically to overcome his anxiety when taken off the respirator? Do the wishes of the family have ethical or legal weight in such cases? Physicians are often sued for keeping a person on a respirator … is the mere fact that the family may sue a justification for not following the expressed wishes of a competent person?” (Garrett, et al., 2001, p. 194)

Ethical Rationale

“There is a dispute as to whether the difference between active and passive killing is of any ethical significance in the context of euthanasia…This dispute has become an important issue in the legal discussion of physician-assisted suicide … The terms are, at least descriptively useful, and since society still accepts the distinction as having some ethical utility, it is disregarded at one’s risk. … should it be considered that active euthanasia ought, with suitable safeguards, be made legal?” (Garrett, et al., p. 195, 2001)

ACTIVITY ONE

Thinking about Joe’s case, answer the following questions. Choose one per question.

Question 1: Would these actions, even at the patient’s request, be classified as active or passive euthanasia?

Active

Passive

Correct Answer: Passive

Joe’s case would count as passive euthanasia, since he’s refusing life-saving treatment. Passive euthanasia is usually considered an act of omission: to take no steps that would, if taken, prevent a patient from dying

Inorrect Answer: Active

Active euthanasia is a deliberate and definite action that would cause a patient to die. The difference is sometimes put this way: passive euthanasia is allowing apatient to die, while active is directly causing them to die.

Question 2: Does Joe have a right to refuse treatment on the respirator?

Yes– The “full recovery” that his family asks for may not be realistic. Staff consider him competent to make his own decisions, and legally he may refuse treatment.

No– Joe’s family know him better than the staff, and they should be granted control over the decisions regarding his care. The health care providers should defer to their wishes in order to avoid a lawsuit.

Correct Answer: There is no correct answer. There may not be a clear answer in this case. If Joe is competent (as we’re told in the study), and there’s a rigorous set of steps in place for staff to determine competency, then he has a moral right to refuse all treatment, and possibly a legal right in many, if not all, states. On the other hand, an argument could be made that Joe can be declared competent only if staff have taken steps to treat his anxiety.

CASE TWO

“Elizabeth Bouvia was diagnosed as having cerebral palsy at the age of six months. At age 10 she was placed in an orthopedic hospital, where she remained for seven years.

She earned a B.S. degree in social work, married and for a year attempted unsuccessfully to have a child. Her husband, whom she had met as a pen pal while he was serving a sentence in jail, has left her. Elizabeth has dropped out of graduate school because of difficulties in finding a clinical placement required for her program. As a result of this, the state has threatened to take away her assistance to transportation.

At this time, Elizabeth Bouvia has admitted herself voluntarily to the hospital on the grounds that she is suicidal, a quadriplegic victim of cerebral palsy and confined to a wheelchair. She has limited control of her right hand and she needs to be fed. She also has severe progressive arthritis that causes constant pain. Her condition is in no way life threatening, and she has a life expectancy of 15 to 20 years.

She seems to have plans to starve herself to death in the hospital, away from friends and relatives. She has refused to eat solid food, The physician has threatened to have her certified as mentally ill so that he can force-feed her. The hospital also has threatened to put her out on the sidewalk. The hospital seeks to transfer her to another facility, but is unsuccessful. In the meantime, the hospital force-feeds Elizabeth. She repeatedly tears the nasogastric tubes from her nose. The tube is forcibly reinserted each time she removes it.

Elizabeth seeks legal assistance. The American Civil Liberties Union enters the case and applies for a court order restraining the hospital from discharging her or force-feeding her. Bouvia testifies that she is no longer willing to live, since she found it disgusting and humiliating to live so dependent a life. She wants to starve to death while nurses give her painkillers and keep her clean and comfortable. She has a metabolic condition that causes her blood to become excessively acidic without food. One internist treating her estimates that she could be dead within five days because of the condition.

The first court decided that Bouvia had a legal right to starve herself to death at home, but not to demand that a health care facility help her while she did this. Another court finally decided that she had a right to hospital care while starving herself to death. Many hearings later, Bouvia was still alive. This might justify a health care provider who said that Bouvia was only seeking attention and knew how to work the system.” (Garrett, et al., pp 194-195, 2001)

Consider These Questions

“Will any of the theories of suicide permit Bouvia to deliberately starve herself to death? Is Bouvia competent? Would the hospital be ethical in getting a guardian ad litum who could then consent to a feeding tube? Would it be ethical for health care providers to cooperate with someone who is not terminally ill and still has the minimum quality of life, that is, is able to interact with others?” (Garrett, et al., p. 195, 2001)

Ethical Rationale

What are the current laws “with regard to the right of non-terminal patients or their surrogates to refuse treatment or demand withdrawal of treatment, including the withdrawal of nutrition and hydration?” (Garrett, et al., p. 195, 2001)

ACTIVITY TWO

Thinking about Elizabeth’s case, answer the following questions. Choose one per question.

Question 1: Will any of the theories of suicide permit Bouvia to deliberately starve herself to death?

Religious and theological: Human lives belong to God.

Human life is so precious: Life is the greatest of all human goods.

Consequentialist: Suicide harms the community.

The Wedge Principle: Suicide harms other individuals.

Greenberg’s Paternalism: These individuals do not really want to die, so efforts to save them are justified.

Correct Answer: There are no correct or incorrect answers.

Although active suicide is discouraged by all of these theories, “All major theories appear to allow room for exceptions” that may open the door to an ethical acceptance of passive suicide (Garrett, p. 171). In the theories offered in this question, this often involves the concepts of compassion and mercy for the suffering individual. However, this does not mean that the facility and caregivers are legally able to condone Bouvia’s requests. (Theories credited to Garret et al, p. 169-173)

Moral theories and ethical principles, and what is their role in health care ethics.

Moral theories are attempts to explain the nature of morality, and to establish foundations for our own moral decisions and moral judgments about the actions of others. In doing so, moral theories look either to human nature or to a source beyond human nature, as religiously oriented theories do. Philosophers have long been interested in trying to understand morality by moving beyond common sense beliefs about right and wrong and to find foundations for common sense beliefs that will both correct them, when needed, and lend them rational support. Here are the moral theories most relevant to health care ethics:

Utilitarianism

Deontology

Natural Law Theory

Virtue Ethics

Ethical principles are not as foundational as moral theories. Rather they can be grounded in common sense moral beliefs about right and wrong and also in widely shared values. The fundamental ethical principles of health care are commonly accepted to be the following:

Autonomy

Beneficence

Non-malfeasance

Justice

Question 2: Should the hospital cooperate with her wishes?

Yes– “The individual person and not the community is the intrinsic good” (p. 170 ) Individual autonomy is paramount; Bouvia has the right to make her own decision to not have her actions interfered with. Court cases have set relevant precedents. Legally, the patient has the right to refuse treatment. Controlled cooperation on the part of the caregivers is appropriate in this scenario.

No– Because Bouvia admitted herself to the care of a healthcare facility as a suicide risk, she relinquished some of her rights. The facility and caregivers have a responsibility to keep her alive.

Correct Answer: No– Because Bouvia admitted herself to the care of a healthcare facility as a suicide risk, she relinquished some of her rights. The facility and caregivers have a responsibility to keep her alive.

Bouvia admitted herself into the facility as a potential suicide. There’s an ongoing debate as to whether anyone who is not terminally ill has a right to receive assistance in ending their own life. Bouvia’s case is complex, since it’s somewhat between active and passive euthanasia. She’s not asking for assistance in ending her life in terms of receiving and having health care workers administer drugs to her that would end her life. However, she is asking for help in dying painlessly (starving herself, but with the aid of painkillers).

Moral theories and ethical principles, and what is their role in health care ethics.

Both moral theories and ethical principles can be used in the health care setting to guide our attempts to reach sound moral decisions and judgments. They support viewpoints by providing them greater objectivity. By using a moral theory or ethical principle, one can move beyond merely voicing an opinion. The theories and principles enable us to construct arguments. When we are able to provide arguments for our views, we offer reasons, or evidence, for our views that should be compelling to others. In other words, moral theories and ethical principles in debates in health care ethics can take us beyond mere subjective feeling and into the realm of rationally supported positions.

ACTIVITY COMPLETE

Congratulations! You have completed the this activity.

For more information to guide you through these questions and prepare you for your assessments, you may refer to these optional websites:

How the Four Principles of Health Care Ethics Improve Patient Care

Basic Principles of Medical Ethics

Principles of Bioethics

References:

Garrett, T. M., Baillie, H. W. & Garrett, R. M. (2013). Health Care Ethics: Principles and Problems, 6th Ed., Prentice Hall, Upper Saddle NJ.

Credits

Subject Matter Expert: Mulberry, Greig

Interactive Design: Rai, Deo

Instructional Design: Lepro, Connie

Project Manager: Hall, Nakeela