In most modern mainstream religions, life is viewed as intrinsically good and worth preserving. We as doctors, come from many different faiths and religion, but we all follow one creed, one oath, the Hippocratic oath. Granted, over the years there have been many variants, but all contain the same underlying principle, that life is foundationally good. This is due to the fact that all things come from life, even death. At the same time, we as doctors must never forget that many of our patients are autonomous, and ultimately free. Physicians must rely on the patient, just as the patient often relies on the physician. The patient is the only one who knows what it is that they themselves what. In the United States, we take our freedom incredibly seriously, and we guard it as we would our most valuable possessions. We as doctors must walk a fine gray line between patient rights and our role as doctors. Nowhere is this more apparent then when dealing with patient assisted suicide, and more commonly, end of life care. Below is this committee’s draft policy, which we feel our hospital should adopt.
In order to accurately meet our patient’s needs, our hospital has adopted a few assumptions. While our hospital’s views may conflict with our patients’ views and values, we believe every human being has the right to life. However, a patient knows himself or herself best, and through this we respect our competent patients’ wishes when concerning their end of life care. Our hospital will respect the decisions of competent patients to refuse treatment without which they will surely die. However, due to the finality of such a decision, we will require that a given patient undergo two psychological evaluations in order to confirm competence beyond any reasonable doubt. Furthermore, our policy aims to assure that decisions of this magnitude are not made in haste. To accomplish this goal, the hospital will require a minimum 48-hour waiting period for treatment to be withdrawn following competence verification. Thus, patients will have ample time to review and reflect over their decision in much the same manner that mandatory waiting period legislation for obtaining handguns seeks to limit ill-advised choices made in the heat of the moment.
The above policy will also apply to terminally ill patients who are deemed competent. Although in this case the patient will eventually die regardless of whether treatment is refused or administered, the choice to refuse treatment is significant in that it often results in a swift death, as opposed to possibly extending life by years. For example, the HIV virus that causes AIDS is currently classified as a terminal diagnosis. However, current treatment strategies can provide patients with additional years of virtually unconstrained life. In light of the gravity of refusing such treatment options, our hospital has decided to handle refusal of treatment decisions in terminal cases with the same care that we do in cases in which refusal of treatment will ultimately result in death.
In both of these situations in which a competent patient is involved, our hospital chooses to firmly respect patient wishes for a variety of reasons. Firstly, America is a country with an extremely diverse population that results in similarly diverse ethical and moral viewpoints. For example, Orthodox Jews hold the belief that all life is a gift of God that people must attempt to preserve in all circumstances. (Veatch 85) Thus, Orthodox Jews will elect to receive treatment regardless of the situation until the patient is moribund. On the opposite end of the spectrum, Christian Scientists believe that the true way to healing is through prayer alone; these people will refuse treatment from traditional doctors in all circumstances, even if it means certain death. As members of such a society with wide-ranging viewpoints, we believe that it is our hospital’s moral duty to respect cultural or religious motivated decisions that may or may not agree with our own personal ideologies. Additionally, our hospital wishes to respect patient-autonomy and freedom of self-determination by striving to adhere to the wishes of competent individuals.
Another issue rises when a patient can no longer make his or her own decisions, but a choice is still necessary to continue treatment. For example, a woman in a coma from a car accident clearly cannot communicate her wishes. Furthermore, in these cases the patient’s prospects are often unknown, and further treatment may or may not prove effective (even though with new technology the life of the patient can be artificially extended indefinitely). In these situations, we honor living wills-written statements previously drafted by the individual that clearly express the patient’s desires. As we have seen with property law, wishes must still be respected after death. A living will allows a patient to express their desires, on a delicate matter in which they would know what was best for themselves. The problem with living wills is that they must be fairly detailed and very specific when describing circumstances. If the situation does not fully match the living will, one cannot follow the terms of the will, since there is no proof that it was the patient’s intention. If this is the case, we defer first to anyone given durable power of attorney, and secondly to the immediate family of the patient. An alternative to the living will is for the individual to grant durable power of attorney to an associate. In this scenario, the patient has authorized his or her colleague to make decisions if the patient is incapable. People holding durable power of attorney can make the ultimate treatment choice for a wider variety of choices than can be applied to the living will. In many cases, though, the patient will have neither a living will nor someone with power of attorney. In these cases we will give the family the ability to make treatment decisions. Specifically, the family included in this situation is the living members of the immediate family: spouse, parents, siblings, and children over 18 years of age. We make this judgment, because the family will often have a good idea of what the patient would want. However, the decision made by the family must be unanimous to be reasonably sure that it is in the patient’s best interests. We are also aware that in some cases the patient might not have a family, or might be in a critical condition where no family can be reached. For these cases, we will pursue whatever treatment the doctor or doctors prescribe.
Moral chaos surrounds incompetent patients. Physicians and others are faced with the decision of how to handle whether or not to treat terminally and critically ill patients. There are three types of incompetent patients. The first is the formally competent, second is the never competent without family, and lastly is the never competent with family. There are ethical and legal standards used in surrogate decisions for the treatment of these incompetent patients.
The first step in dealing with formerly competent patients is to talk to other people who know the patient, in order to find out if the patient ever expressed their wishes for the type of care they want or do not want. What is increasingly done today is an advanced directive. This is a written expression of the patient’s wishes. There are two types. The first is a substantive directive; this records the patient’s substantive wishes about medical treatment. The patient may specify the type of treatment that they would want or their desire to refuse treatment. The second type is a proxy directive. This is where the writer specifies a person to serve as the patient’s surrogate decision maker in the chance that the writer may become unable to speak for himself. This is of particular importance when the patient does not want their next of kin to be their spokesperson. Legally, the spouse is the next of kin and this can be a problem for feuding spouses. Therefore, the patient may want a friend or relative to be their spokesperson. The standard the proxy uses for making the medical decision is called a substituted judgment. This judgment is based on the incompetent’s beliefs and values as they were expressed while the patient was competent. A decision that the patient made while competent is usually held as valid and binding, this could be called the principle of autonomy extended. The advanced directive expresses the patient’s own beliefs and values. They should be up held even if the physician does not understand them or agree with them. The advanced directive was originally called the “Living Will.” It was first proposed in the 1930s and the Euthanasia Educational Council promoted the advanced directive that exists today in the 1970s.
The second type of incompetent patient is one in which they have never been competent and are without family or any agents that could act as surrogates. Some examples would be the elderly who have no living relatives or isolated adults that are estranged from their family. The autonomy principle is impossible to use for this group, therefore the principle of individual (Hippocratic) utility is used. This principle maximizes the net welfare of the patient. As we assumed earlier, our hospital will always assume that life is foundationally good, and there is no moral or legal basis for a physician to stop treatment for this type of patient. There has to be someone to decide for this patient and there has to be some standard used for the decision. The legal standard that must be used is the best interest standard. This is used by whatever decision maker is identified and the judgments are based on what are taken to be objective beliefs about what is good for the patient. Currently, there is no clear answer for who the surrogate should be for the never-competent patient without family. Physicians would not be good because they may have systematic biases that will lead them toward certain kinds of decisions. Also, the primary physician is in the best position to serve as a check on the surrogate. Therefore the check will be lost if the physician becomes the surrogate.
The last group of patients for whom a decision-making process must be found is for those who never expressed themselves while competent or who have never been competent but have family members or other people to function as surrogates. The next of kin should be the surrogate, unless they demonstrate to a judge to be incompetent, have misinvested interests, or unwilling to fill the position. The family should do its best to serve the patients best interest. However, problems may arise when there is a difference in opinion. There should be a limited range of discretion among plausible choices. Sometimes the family may make a choice that in the eyes of the physician is not the best choice. Therefore the family would have a lower status in the medical decision process, with priority going to the court. The courts have never formally stated this principle of granting discretion to the family, which is a version of the principle of limited familial autonomy. While the family has the right and duty to interpret a value system for the incompetent patient, they have limited authority to choose the values for the patient in our society.
Making decisions for incompetent patients can be a difficult task for all those involved, especially since there is a debate over the definition of death. Today, there is an increasing shift in favor of a brain-oriented definition of death. Also, a person who is in a permanent vegetative state is not terminally ill by definition. Problems may also arise when the entire family does not come to a consensus about the course of action they want the hospital to take in caring for the patient. It is our policy that if the whole family does not come to a consensus of whether to treat a patient or not, the case will be argued before court. Problems may also arise in the choices made by parents who are divorced, about the treatment they want for their child (who is a minor). It is our policy to take the side of the parent who has sole custody. If there is dual custody, then the matter will also be brought to court.
Physician assisted suicide is always a delicate issue wherever it is legal, because of the various religious and social stigmas that come with it. For example, Judeo-Christian belief is that life is a sacred gift from god, and selfish individual should not take it. As a comprehensive hospital, we feel the need to set regulations for who should be allowed to employ the option of physician assisted suicide (PAS). In order to do this, we will set standards for exactly what type of ailments will be required for a patient to be deemed eligible for PAS.
The first requirement for a patient to have a PAS is that he or she must have a terminal illness. Examples of terminal diseases include terminal cases of cancer, such as leukemia, lymphoma, and myeloma, and AIDS. If the patient has one of these diseases and is at a point where the disease has progressed far enough so that it is guaranteed to be fatal, then the first requirement for PAS has been met. The second requirement is that the patient must have at least two psychiatric examinations. During the examinations, the patient must be able to demonstrate to the psychiatrist that he or she has a real reason for wanting to end his or her life at that moment, aside from the fact that death is inevitable due to the disease. Viable reasons include, but are not limited to, the patient being able to prove that he or she has lived a full life already, or that the quality of life with this terminal illness would be such that living with its presence is unbearable. If and only if the patient has managed to show without a doubt that he or she has ample reasons for desiring PAS, and the disease that the patient has is indeed terminal, then we are obligated to let the patient proceed with the treatment. In order to prepare the immediate family of the patient, we will help to prepare doctors on how to help families cope with the decision that the patient has made, in much the same way that they would be informed in the event that the patient has chosen to refuse treatment.
The above statements are all under the assumption that the patient in question has proven that he or she is competent to make a decision of this magnitude, and that he or she is of the legal age to have such a request honored. If this is not the case, then we will have to take into account special cases. If the patient is considered incompetent to request PAS, then the treatment shall not be given to the patient under any circumstances. By no means shall a legal guardian be granted the power to request the death of an adult patient that they are caring for. However, if the patient cannot make the decision for him or herself because the patient is not of the legal age of consent, then it may be possible for the patient to have this option available. The requirements in this case are similar to those above, with the following differences. First, the legal guardian or guardians, whichever the case may be, must give consent along with the minor who has the disease. If all are not in agreement, then the process cannot proceed. Second, all must be present during the psychiatric meetings, and they as a group must convince the psychiatrist that the child would not have a lifestyle worth living. If and only if both of these events come to pass, then the child may be permitted to undergo PAS.
Because as a hospital, our primary concern is healthcare and trying to prolong and enrich the lives of our patients, we offer PAS only as a last resort to ease the lives of patients who are faced with a long, arduous struggle with a disease that there is currently no known cure for. We will always defer towards treating a patient to the best of our ability, unless the patient can demonstrate ample reasons both medically and psychologically as to why we should assist the patient in taking his or her life. If at any point, up to the moment before death, the patient decides not to go through with the suicide, that request will be honored. However, it is our duty to assist our patients in the best way that we can, and if that means that we have to actively assist in the patient’s death in order to relieve the patient from living a completely undesirable life, then we will comply.
Anything having to deal with the issues of death and dying is always an area of difficulty for humans to deal with. As a hospital, our primary concern towards all patients is to make sure that they live, and then to help them achieve some sense of the life that they had before they came in. However, this is clearly not possible in all cases. Any case pertaining to end of life matters must be dealt with in a different manner than other cases, because there are new sets of rules that come into play. Once it has been confirmed that the patient has a terminal illness, this should be brought to the patient’s attention as soon as possible so that we can arrange talks about what the patient feels is the best thing to do. Of course, we expect that all of our doctors will do their best to help their patients by default, but in the event that the patient looks like he or she is really going through some suffering that shows absolutely no sign of relenting, then we have some options for the patient to consider.
Of course, it is not the case that we feel as if we have the ability to determine for the patient who should try to undergo a treatment that would prolong their life or who should stop living. The patients themselves, or the ones who have been appointed to care for the patients should the patients be deemed unable to take care of themselves, are the ones who make the decision, without exception. The only foreseeable rationale for ending the hospital’s treatment of a patient that we will consider is if the patient can prove that the quality of life will have degenerated so far that the patient honestly and deeply feels that he or she no longer possesses the desire to live. In the case that the patient is not able to make the decision, then those in charge of making the decision must all agree that the patient would have come to the same decision that they have come to.
Essentially we feel that while as doctors, our primary concern is the health of a patient. However, health consists of not only physical but also mental aspects, and this is something that has only come into consideration lately. It is for this reason that we need to have policies to accurately help patients who have come to the realization that they no longer wish for us as doctors to actively try to prolong their lives.
The above is our hospital’s policy concerning end life care, which we hope to adopt. First and foremost, we believe that life is foundationally good, and unless we are given specific instructions through the aforementioned procedures, we will always try to sustain life. At our hospital we will also respect the moral beliefs of our doctors. At no time will a doctor be made to perform the PAS procedure, or end the life of another. If the doctor does not feel comfortable patients requests, they will be given the opportunity to make a lateral transfer, and give the case to a doctor with no moral qualms. In conclusion, it is only the prerogative of an individual to decide what is the best life for him or herself. We will always try to respect our patients beliefs, and carry out their respective wishes, as long as they fall in accordance to our guidelines.