Ethics at the End of Life

Question 1

According to Atul Gawande what are five questions one should ask those/yourself when facing mortality?

Answer 1

1. What is your understanding of where you are and of your illness?
2. Your fears or worries for the future?
3. Your goals and priorities?
4. What outcomes are unacceptable to you? What are you willing to sacrifice and not?
   And later,
5. What would a good day look like?

Question 2

How do doctors tend to prefer to die?

Answer 2

Without aggressive treatment

Question 3

What ethical principles should guide decisions about the end of life?

Answer 3

The same as normal:
Respect for autonomy
Beneficence
Non-maleficence
Justice
Also present: law, and sanctity of life

Question 4

When did the care at the end of life movement become notable in the UK

Answer 4

Hospice movement started in 1967 – St Christopher’s Hospice
Founded by Dame Cicely Saunders
Based on “a concept where there is a shift of emphasis from conventional care that focuses on quantity of life, towards a commitment to care which enhances the quality of life.” (p1, The Hospice Movement, Help the Hospices)

Question 5

What is the hospice movement?

Answer 5

The focus of care in the hospice (palliative care) is based on a holistic view of the person:
- Physical
- Emotional
- Psychological
- Spiritual
- Social
Often there is also a focus on pain management

Question 6

What is palliative care

Answer 6

Dude you literally did this as a job lol
Definition is:
“[that which] relieves the symptoms of a disease or condition without dealing with the underlying cause. (OED)”
And somehow they don’t mention living in a bed in a blacked out 4x6m room for four weeks while the cancer eats at your pancreas

Question 7

What is the definition of euthanasia?

Answer 7

X intentionally kills Y, or permits Y’s death, for Y’s benefit

Question 8

What is the definition of active euthanasia?

Answer 8

: X performs an action which itself results in Y’s death

Question 9

What is the definition of passive euthanasia?

Answer 9

X allows Y to die. X withholds life prolonging treatment or withdraws life-prolonging treatment

Question 10

What is the definition of voluntary euthanasia?

Answer 10

Euthanasia when Y competently requests death their-self

Question 11

What is the definition of non-voluntary euthanasia?

Answer 11

Euthanasia when Y is not competent to express a preference

Question 12

What is the definition of involuntary euthanasia?

Answer 12

Death is against Y’s competent wishes, although X permits or imposes death for Y’s benefit

Question 13

What is the definition of suicide?

Answer 13

Y intentionally kills themselves

Question 14

What is the definition of assisted suicide?

Answer 14

X intentionally helps Y to kill himself

Question 15

What is the definition of murder?

Answer 15

X intentionally kills Y

Question 16

Provide an example of active euthanasia

Answer 16

R v Cox, 1992

Lillian Boyes was a 70 yr old woman with very severe rheumatoid arthritis, the pain of which seemed to be beyond the reach of analgesics
She was expected to die within a matter of days or weeks
She asked her doctor (Dr Cox) to kill her
Out of compassion for his patient, and because it was what she wanted him to do, Dr Cox injected a lethal dose of potassium chloride
He was charged with attempted murder (he wasn’t charged with murder as, given her condition, she may have died from the disease not the injection)
He was found guilty of attempted murder

Question 17

Provide an example of passive euthanasia

Answer 17

Airedale NHS Trust v Bland, 1993

In 1989, 21 yr old Anthony Bland was seriously hurt when crushed by overcrowding at the Hillsborough football stadium
Attempts to resuscitate him resulted in his being permanently unconscious and with no prospect of ever gaining consciousness (permanent/persistent vegetative state)
After 3 years, the Hospital Trust applied to the court for a ruling as to whether it would be lawful to discontinue Bland’s life support which would inevitably lead to death
The case went to the House of Lords

The court recognised there was the intention was to cause death. Lord goff stated to actively to bring a patient’s life to an end is:-
“to cross the Rubicon which runs between on the one hand the care of the living patient and on the other hand euthanasia - actively causing his death to avoid or to end his suffering. Euthanasia is not lawful at common law”: per Lord Goff at p. 865 F.

Withdrawal of treatment was, however, properly to be characterised as an omission. An omission to act would nonetheless be culpable if there was a duty to act. There was no duty to treat if treatment was not in the best interests of the patient. Since there was no prospect of the treatment improving his condition the treatment was futile and there was no interest for Tony Bland in continuing the process of artificially feeding him upon which the prolongation of his life depends.

Question 18

Provide an example of non-voluntary euthanasia

Answer 18

DPP decision on prosecution – the death by suicide of Daniel James, 2008

Daniel (23 yrs old) was seriously injured in a rugby accident & paralysed
He died at the Dignitas clinic in Switzerland in 2008, accompanied by his parents
Enough evidence existed to prosecute Daniel’s parents & a family friend
DPP decided that it was not in the public interest to prosecute

Note: DPP will exercise his/her discretion retrospectively, once all the facts of the police investigation are in front of him/her, not prospectively

Question 19

Provide an example of attempted assisted suicide

Answer 19

R (on the application of Pretty) v Director of Public Prosecutions, 2001

Dianne Pretty suffered from motor neurone disease (progressive & degenerative terminal illness – person’s mental faculties remain sharp, while their body fails)
Mrs Pretty’s husband was willing to help her commit suicide but the couple were anxious that he would be prosecuted (under Suicide Act, 1961)
Mrs Pretty asked the DPP to give an undertaking that he would not consent to Mr Pretty’s prosecution
She sought judicial review of his refusal
She died 12 days after her appeal was rejected by the ECtHR

Question 20

Discuss pain relief in the bounds of the doctrine of double effect (DDE)

Answer 20

You cannot give a drug with the intention to kill another person
However, increasing doses of painkiller can be given to alleviate pain, with the possibility of causing death
As we’ve discussed before – this involves looking at the distinction between intending death, and foreseeing death
As well as ethically noting a difference between intending and foreseeing…

Question 21

Provide two cases that provide examples of the ethics of acts vs omissions

Answer 21

The cases of Smith & Jones

The cases of Robinson & Davies

The cases of Smith & Jones
Smith sneaks into the bathroom of his 6 yr old cousin and drowns him, arranging things so that it will look like an accident. The reason Smith does this is that the death of his cousin results into his coming into a large inheritance.
Jones stands to gain a similar large inheritance from the death of his 6 yr old cousin. Like Smith, Jones sneaks into the bathroom with the intention of drowning his cousin. The cousin, however, accidentally slips and knocks his head and drowns in the bath.
Jones could easily have saved his cousin, but instead stands ready to push the child’s head back under. However, this does not prove necessary.
—-

The cases of Robinson & Davies
Robinson does not give £100 to a charity that is helping to combat starvation in a poor country. As a result, one person dies from starvation who would have lived had Robinson sent the money
Davies does send £100 but also sends a poisoned food parcel for use by a charity distributing food donations. The overall and intended result is that one person is killed from the poisoned food parcel and another person’s life is saved by the £100 donation

Question 22

What are some stated reasons for allowing active euthanasia?

Answer 22

Consistency
From passive to active
From painkillers to lethal injections
Appeal to principles: autonomy and beneficence
Benefits of regulation

Question 23

What are some stated reasons against allowing active euthanasia?

Answer 23

Respect for sanctity of life
Palliative care
Exploitation/manipulation
Contrary to aims of medicine
Slippery slope

Question 24

What are the laws on euthanasia in the Netherlands?

Answer 24

Euthanasia is allowed if:
Patient is incurably ill
Patient is experiencing unbearable suffering
Patient has requested his/her life be terminated
Termination is performed by the patient’s own doctor

Three points to note:
Advance directives for euthanasia are allowed
Children over the age of 12 can request euthanasia
Euthanasia of severely disabled newborns is allowed

Question 25

What are the laws on euthanasia in Switzerland?

Answer 25

Assisted suicide is legally condoned
Assisting someone to commit suicide is illegal ONLY if the motive is selfish; if the motive is unselfish, then it is NOT illegal
Two organisations which help people to die are
EXIT
Dignitas
The person assisting does not have to be a physician, person does not need to be a resident of Switzerland

~ 300 suicides are assisted by right-to-die organisations in Switzerland

Question 26

What are the laws on euthanasia in Oregon, USA?

Answer 26

Physician-assisted suicide is legal in Oregon, not euthanasia (note: euthanasia is illegal in the US, PAS varies from state-to- state)
Death with Dignity Act 1994
Only applies to residents of Oregon
Note: in PAS, the doctor provides the medicine but does not administer

Question 27

What are some other nearby countries that allow euthanasia?

Answer 27

Belgium since 2002

Canada since 2015

Question 28

What are the laws on organ donation in the UK?

Answer 28

UK is moving away from an opt-in system*

Reasons why potential donors don’t become actual donors include:-
Tests for brainstem death not carried out
Refusal by relatives
Medical contraindication to donation
Relatives not asked about donation
Heart stopped beating before brainstem death complete
Organs offered but not retrieved (BMA report, cited H, S & H, 2008)

Do not allow directed/conditional donation

What factors determine who gets the organs? Compatibility, age, proximity to centre

Question 29

What is the state of opt in organ donation system in UK?

Answer 29

Wales: opt out system from 2015; England from Spring 2020; Scotland from Autumn 2020; NI – Opt in – Public Consultation in 2021