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End of Life Issues 2

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Professor walter sisto

on 12 June 2017

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Transcript of End of Life Issues 2

Lecture 2: End of Life Issues
Test Case: The Arizona Case

1) Catholic Hospital

2) 27 years old, 11 weeks pregnant

3) Arrives at the emergency room,,,,she is seriously ill with pulmonary hypertension
- condition limits heart and lung function and is reportedly made worse and even fatal by pregnancy

4) Phoenix hospital physicans and moral theologian assessed the woman’s condition as dire

5) a D&C (dilation and curettage) was recommended


1) Based on Church Teaching, was the hospital moral for allowing this abortion?

2) Could the Catholic hospital legally deny this women her abortion?
-Federal Emergency Medical Treatment and Labor Act (EMTALA), which requires that a patient in an emergency must be treated or—if the condition cannot be medically managed—safely transferred to another hospital.
-Religious Freedom-to deny abortion or deny transfer???
-Could a Jehovah’s Witness hospital legally refuse to give a transfusion—or facilitate a transfer—for a Catholic patient bleeding to death??

Definition: The deliberate cessation of prenatal human life

Direct = procured/willed/intentional
Indirect = accidental/inevitable (Spontaneous Abortion = Miscarriage)
Roe v. Wade (1973)
Challenge to Church Teaching

vital maternal-fetal conflict
-Such a conflict involves a medical crisis in which

(1) no procedure can save both mother and child,
(2) no procedure can save the child,
(3) only one procedure can save the mother,
(4) that procedure entails ending the pregnancy.
Positions of those who favor:
a woman has a right to privacy
a woman has a right to do whatever she wants to her body

Acceptable in some circumstances but not others
Rape & Incest
Life of the mother
Selective Abortion: Multiple birth pregnancy...when all fetuses cannot reach term and therefore one or more fetuses are aborted in order that one or more fetuses can survive.
-The fifth commandment: “Thou shall not kill”
-Respect… “human life in all its manifestations and stages of development with the special care that it deserves”
-The Catholic Church states that life begins at Conception not when the fetus is viable.

1974 Declaration on Abortion states:
“From the time ovum is fertilized a life is begun…right from fertilization the adventure of human life has begun…”
Catholic Tradition
-Never use life as a means to an end
-Never directly kill an innocent human person

Generally apply the Catholic Moral Theory

Moral Action = Good Action + Good Intention + Indifferent/Good Circumstances

Cases of rape or incest?

What to do when Mother's life is in danger?

CMT--Does not work well
Indirect Abortions are moral
-Logic: Doctrine of Double EFFECT

Direct Abortions are immoral
-never directly target the life of the child
Doctrine of Double Effect (DDE)
1) Intention must be good
2) Bad effect cannot be the means to the good effect
3) Proportionality: Good gained must outweigh the evil effect
-Greek "good death"
-Debate over what this means
-An action or omission of an action which of itself or by intention causes death in order that all suffering may be eliminated
Something is euthanasia if
-there is an intention that the person die in order to eliminate suffering

intention can drive action/inaction

For many:
intentional decision not to keep treating someone, knowing this means they likely will die of their disease ("let die")
, is not the same as
intending to kill someone

"intending death" is not "causing death, even though it is not intended"

Euthanasia is

Oregon (legal exception)
-The Oregon Death With Dignity Act was passed in November 1994 by a margin of 51% to 49%
-PAS (Physician Assisted Suicide) is legal
-lethal dosage of pills
-request from doctor
-intention to end life
-Grave condition (incurable condition, suffering,imminent death)
-more than one doctor must attest

Also-Assisted Suicide Organizations (e.g.Compassionate Choices)
-Inform/counsel patient how to end their life
-e.g. where to buy lethal dosage, and how to make it seem like natural death
-Assist during death, but never touch patient
-Legal loophole
Palliative care
-treatment for pain (Morphine/ opiate drugs)
-build tolerance
-more drugs for same relief
-eventually drug will cause death via respiratory failure

-pro-PAS = same as euthansia
Do we agree?

Based on DDE:
-Caregiver who administers the morphine that results in the death of the patient is moral
-This is not Euthanasia that always relies on an unethical intention

1) Good intention (principle that guides the action)
2) good effect (pain relief) is not achieved via the bad effect (death)
3) Goodness out weighs the Badness of the act
[need to consider the status of illness, prognosis, degree of suffering, toll on family]

-In certain circumstances use of morphine that result in death is euthanasia
Eg. Young Man recovering from a Car Wreck
Fail condition 3 of the Doctrine of Double Effect if recovery was inevitable
-probability of causing death (Bad effect) would outweigh pain relief (Good effect)

-may pass conditions 2 and 3 of DDE
-but fail condition 1
Christian/Jewish/Islamic/Hindu perspectives

-Intentional killing of innocent people is always gravely immoral.....even if good results

-"Why not say—as some slanderously claim that we say—“Let us do evil that good may result”? Their condemnation is just!" (Romans 3:8)

-Not just revelation tells us this, but

PAS is a different issue than
Withholding or Withdrawing Life-Sustaining Treatment

Not vitalism
-Preserve Life at all costs
-Good life= length of Life (what is their Big-Picture)
Quality-of -life judgment
-when to "pull the plug"
-Is the intention to kill? ---if so, wrong
????????? then what ???????
For many Christians:
-if intention is to stop prolonging life of patient with burdensome/useless treatments, then it is morally permissible
1) goal is to prolong life and
live more fully
2) evidence that on occasion people continue to live
-if continuation of life, then aim is not frustrated

Extraordinary Means:
burdensome/useless without intending to end life
-simply prolongs life
-examine case by case
-respirator maybe extra for a PVS patient, but not for someone undergoing serious surgery

Ordinary Means:
not burdensome/useless
-Refusal driven by intention to end someone's life
-Immoral to end
Test Case: Terri Shiavo
-Husband desired to stop feeding and hydration
-parents disagree

Removal of Feeding tube and hydration:
-Is it Ordinary or Extraordinary means?
-Do we intend death when we remove feeding tubes?
-Did the state of Florida execute Mrs. Shiavo?
Catholic Ethics: JPII
yes, immoral
-First, providing nutrition and hydration is a form of care, not a form of treatment. (ordinary means)
-Second, withdrawing a feeding tube is essentially to aim at death. (fails condition 1 of DDE)
-Many argue shift in Catholic position, which did not define ordinary means in such rigidity

Bishop'/s' response:

-Phoenix Bishop Thomas Olmsted announced the automatic excommunication of Sister Margaret McBride

For these reasons:
-“As the Church has said many times, direct abortion is never permissible because a good end cannot justify an evil means.”

-Even though the abortion “is likely to improve the functioning of the organ or organs, but only in an indirect way, i.e., by lessening the overall demands placed upon the organ or organs, since the burden posed by the pregnancy will be removed”, you cannot directly end life

-human life is never a means to an end

-evidence to the contrary...cites a study by Dr. Byrne...indicates that there have been successful interventions for pregnant women with pulmonary hypertension that have enabled both mother and child to survive.
Is a philosophy of caring for dying persons and their family
nature and pain of those dying
Caregivers did not always realize or acknowledge the level of pain and other forms of distress being experienced by individuals
need for end of life conversations
prepare for end-of-life decisions
-involve patient, family, and professionals
provide effective resources
respond to worry that wishes may be ignored
"Your pain cannot be as bad as you say"; "We have to save the really strong medication when you really need it1"
At the center of hospice is the belief that each of us has the right to die pain-free and with dignity, and that our families will receive the necessary support to allow us to do so...
Hospice focuses on
caring, not curing a
nd in most cases care is provided in the patient's home. Hospice care also is provided in freestanding hospice centers, hospitals, and nursing homes and other long-term care facilities. Hospice services are available to patients of any age, religion, race, or illness. Hospice care is covered under Medicare, Medicaid, most private insurance plans, HMOs, and other managed care organizations. (National Hospice and Palliative Care Organization)

Hospice Team
Spiritual Counselors
Home Health
"Role Blurring"
-The U.S. Supreme Court ruled in 1997 in Washington v. Glucksberg that there is no federal constitutional substantive right to assisted suicide. In a 1997 companion case, the U.S. Supreme Court ruled in Vacco v. Quill that there is no federal constitutional equal protection right to assisted suicide.
-illegal in most states
-Immoral for Catholics, many Christians, Muslims, Jews, many Hindus/Buddhists
-results in sin or bad karma
-life is sacred
-The states of California, Washington, Michigan and Maine rejected ballot referenda questions to legalize physician-assisted suicide in their respective states. The Supreme Court of Alaska in Alaska v. Sampson declared there is no state constitutional right to physician-assisted suicide, as did the Florida State Supreme Court in McIver v. Kirscher. The Hawaii State Senate voted down a bill to legalize physician-assisted suicide.
-Study of 10,000 doctors in the US stated that approximately 46% of physicians agree that physician-assisted suicide should be allowed in some cases; 41% do not, and the remaining 14% think it depends.

increase dosage
increase pain

Palliative Care versus Euthanasia
What about situations where a caregiver
administers morphine to her patient:

-morphine is a poison and will kill the patient
-many cases patients do die from morphine
-Is this a form of Legalized Euthanasia?
PVS (Persistent Vegetative State)
Dilemma: Take off respirator that will result in death
Is the use of potassium chloride (i.e. PAS) to end a patient's suffering moral?
Based on this perspective it is immoral!
10 principles of Hospice Care
1-Hospice is a philosophy, not a facility, whose focus is on end-of-life care
2-Hospice philosophy affirms life not death
3-Hospice philosophy tries to maximize present quality of life
4-Hospice offers care to the patient-and-family-unit
5-Hospice is holistic care
-listens to concerns
-assist in physical, psychological, social, and spiritual tasks
6-Hospice offers continuing care and ongoing support to family members coping with dying, death, and loss both before and after death
7-Hospice approach combines professional skills and human presence through interdisciplinary teamwork
8-Hospice programs make services available 24/7
9-Participants in hospice are given special attention to supporting each other
10-Hospice philosophy can be applied to a variety of individuals and family members who are coping with a life-threatening illness, dying, death, or bereavement
-require notice that death is imminent
6-You need to sign a DNR!
do-not-resuscitate (DNR) order tells medical professionals not to perform CPR. This means that doctors, nurses and emergency medical personnel will not attempt emergency CPR if the patient's breathing or heartbeat stops. (NYS department of health)
-consent by both doctor and patient or proxy
CPR - cardiopulmonary resuscitation - refers to the medical
procedures used to restart a patient's heart and breathing
when the patient suffers heart failure.
-e.g. mouth-to-mouth resuscitation and external chest compression, electric shock, insertion of a tube to open the patient's airway, injection of medication into the heart and in extreme cases, open chest heart massage.
1-Ethical?-may be ordinary or extraordinary means
2-Violate DNR? (NYS-Good Samaritan law-immunity if assist in an emergency)
FACT: No lay person has ever been successfully sued for performing CPR on a victim of cardiac arrest (American Heart Association)

1-Hospice makes death come sooner.
Hospice neither hastens nor postpones dying. The aim is to improve the quality of remaining life so patients can enjoy time with family and friends and experience a natural, pain-free death. In some cases, hospice care can extend life.

2- Hospice is giving up hope; it’s better to fight for life.
Most terminally ill patients experience less anxiety by refocusing hope on what might be realistically achieved in the time remaining. If continuing uncomfortable and painful curative treatment for an illness is fruitless, hospice patients benefit more from having their symptoms treated instead.

3-A hospice patient who shows signs of recovery can’t return to regular medical treatment.
If a patient’s condition improves, they can be discharged from hospice and return to curative treatment, or resume their daily lives. If need be, they can later return to hospice care.

4-A hospice patient can’t change his or her mind and return to curative treatment even if their prognosis hasn’t changed.
A patient can go on and off hospice care as needed—or if they change their mind and decide to return to curative treatment. They may also enter hospital for certain types of treatment if it involves improving their quality of life.

5-Hospice care is limited to a maximum of six months.
In the U.S., many insurance companies, as well as the Medicare Hospice Benefit, require that a terminally ill patient has a prognosis of six months or less to start hospice, but a terminally-ill patient can receive hospice care for as long as necessary.

7-Need a Living Will
-document stating advanced directives with respect to
-terminal illness, p.v.s., or end stage of life
-may or may not include DNR
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