Department of Graduate School

Masters in Science of nursing

Course Subject: Bioethics

End of Life Issues

Definition of Death
The Uniform Determination of Death Act 1981 (UDDA) wording specifically states:
An individual who has sustained either (1) irreversible cessation of circulatory and respiratory
functions, or (2) irreversible cessation of all the functions of the entire brain, including the brain
stem, is dead.
Common elements of a good death:
Adequate pain and symptom management.
Avoiding a prolonged dying process.
Clear communication about decisions by patient, family and physician.
Adequate preparation for death, for both patient and loved ones.
Feeling a sense of control.
Finding a spiritual or emotional sense of completion.
Affirming the patient as a unique and worthy person.
Strengthening relationships with loved ones.
Not being alone.

Euthanasia
Etymologically, euthanasia means easy death (from the Greek word eu easy and thanatos
death. More strictly, it means painless, peaceful death; it is the deliberate putting to death, in
an easy, painless way, of an individual suffering from an incurable and agonizing disease. It is
popularly known as mercy killing, insofar as it is regarded as a merciful release from an
incurable and prolonged suffering.
The modern concept of euthanasia came into being in the 20th century after the invention of lifeextending technologies. These technologies help to save the lives of many people who suffer
serious illness or injury. However, the use of modern medical technologies can also keep patients
alive who are a) living in a situation that they consider to be worse than death, b) are in a coma
or c) are in a persistent vegetative state (PVS).
Persistent vegetative state, as defined by the Multi-Society Task Force on PVS, is one in which
there is complete unawareness of the self and the environment, accompanied by sleep-wake
cycles, with either complete or partial preservation of hypothalamic and brainstem autonomic
functions.

Classification of Euthanasia:
1.
2.
3.
4.

Active and voluntary euthanasia

Passive and voluntary euthanasia
Active and nonvoluntary euthanasia
Passive and nonvoluntary euthanasia

These thoughts can be brought about by several factors including unrelieved pain, depression,
feelings of loss of control, fear of isolation, concern for family and a sense of hopelessness.
It is important for nurses not to judge or isolate patients who have suicidal thoughts. Instead
nurses should use this opportunity to open the lines of communications, discussions of suicide
does not increase the risk of follow through. Creating an environment where a patient is
comfortable expressing thoughts can help diminish feelings of isolation and provided needed
support.
Moral issues and views on Euthanasia
A range of different ethical and moral positions and arguments exist regarding active euthanasia:
Terminating life at the request of an individual is not immoral because it is the individuals
decision to make.
Terminating life may be justified in some circumstances if, and only if, there is compelling
evidence that to continue living would be more harmful to the person than dying.
Terminating life is unethical in todays society because there are not enough protections that
would allow for a just and fair practice of euthanasia.
Terminating life is always unethical because it violates a) the moral belief that life should
never be taken intentionally or b) the basic human right not to be killed.
Preservation of human dignity euthanasia aims to preserve human dignity until death. Not
only does one have a duty to preserve life but one has also the duty to die with dignity. To die
with dignity means that one should be able to make decisions to die when dying would be better
than to go on living with an incurable and distressing Illness.
Death is intrinsically bad
This amounts to saying that even if death is welcome and desirable from the point of view of a
patient, it is nonetheless bad. When holding that death is intrinsically bad, one asserts that there
is something bad or detrimental about death over and above the fact that death may put an end to
what we find valuable about life.

The doctrine of the double effect

In passive euthanasia the physician's intention is not to end the life of a patient. Rather, the
intention is, say, to avoid burdening a patient with pointless treatment. This might be morally
acceptable. Active euthanasia, on the other hand, is not morally acceptable, since active
euthanasia involves the intention that a patients life is ended.
When an act is foreseen to have both good & bad effects, the principle of double effect is
applied.
In order that such act be permissible the following conditions should be met:
1. The action itself must be good or at least neutral
2. The good effects is the one directed intended by agent & not the evil effect
If wrong, it must be wrong because of what the action aims at, or because of what it achieves.
Thus, we cannot hold that an action is wrong if we recognize that it is done with morally
praiseworthy intentions and accept that it has only morally good consequences.
Passive versus Active Euthanasia
Physicians do not kill a patient by omitting treatment, but rather the disease takes the patients
life.
Patients have a right to a death with dignity. Allowing a dignified death to occur naturally is
a moral act, different from active euthanasia.
The withholding or withdrawal of life-sustaining treatment (WWLST), such as mechanical
ventilation, cardiopulmonary resuscitation, chemotherapy, dialysis, antibiotics, and artificially
provided nutrition and hydration, is ethically acceptable. WWLST is allowing the patient to die
from their underlying medical condition and does not involve an action to end the patients life.
ANA Position Statement (04/24/13)

Application of Ethical Theories

Natural Law Ethics
1. Condemns mercy killing
2. Euthanasia is intrinsically wrong because it implies the direct deliberate killing of
an individual-hence, it is murder
3. Even though the motive is good, the good does not justify the evil means in this
case
Utilitarian principles of utility
it seems that its formulation about the greatest happiness and benefits for the
greatest number of persons may render euthanasia legitimate
Others may interpret the utility principles, which argues that since life is a
necessary condition for happiness, that it is mostly wrong to destroy that
condition, since by doing so the possibility of promoting happiness is forever lost
Moreover, organ-transplant advocates may argue that a comatose patient is going to die anyway,
and his transplantable organs will benefits those who are in need (upon informed consent or with

the permission of his immediate relatives), in this way, promoting the greatest benefits for the
greatest number of individuals to be benefited will make euthanasia morally acceptable.
On Rawlss concept of justice,
Which argues that no amount of social good or welfare can override the
inviolability of the individual it appears as if euthanasia would be illicit and
unacceptable
However, a persons inevitability demands that his dignity be preserved and
justice be served if and when his death would be as painless and nonviolent as
possible
For him to live and suffer needless pain and agony would be doing him more
injustice than justice, more harm than good
Statement of ANA Position: The American Nurses Association (ANA) prohibits nurses
participation in assisted suicide and euthanasia because these acts are in direct violation of Code
of Ethics for Nurses with Interpretive Statements (ANA, 2001; herein referred to as The Code),
the ethical traditions and goals of the profession, and its covenant with society. Nurses have an
obligation to provide humane, comprehensive, and compassionate care that respects the rights of
patients but upholds the standards of the profession in the presence of chronic, debilitating illness
and at end-of-life. (April 24, 2013)
Euthanasia is illegal in the Philippines. In 1997, the Philippine Senate considered passing a bill
legalizing passive euthanasia. The bill met strong opposition from the country's Catholic Church.
If legalized the Philippines would have been the first country to legalize euthanasia. Under
current laws, doctors assisting a patient to die can be imprisoned and charged with malpractice.

Right to Life
The right to life is a moral principle based on the belief that a human being has the right to live
and, in particular, should not to be unjustly killed by another human being. The concept of a right
to life is central to debates on the issues of euthanasia, capital punishment, abortion, self defense
and the morality of war.
Right to die
The right to die is an ethical or institutional entitlement of any individual to commit suicide or
to undergo voluntary euthanasia. Possession of this right is often understood to mean that a
person with a terminal illness should be allowed to commit suicide or assisted suicide or to
decline life-prolonging treatment, where a disease would otherwise prolong their suffering to an
identical result. The question of who, if anyone, should be empowered to make these decisions is
often central to debate.

Advance Directive

Allows competent patients to indicate their health-related preferences or a surrogate decision

maker prior to becoming incapacitated.
Types of Advance Directives
1. Living will: written instructions related to health- related preferences in the event the
patients becomes incapacitated and is unable to communicate his or her wishes
otherwise
2. Durable power of attorney: A surrogate is designated to make health care decisions on
behalf of incapacitated patients
3. Do Not Resuscitate document is a binding legal document that states resuscitation
should not be attempted if a person suffers cardiac or respiratory arrest.
4. Organ Donation
When the patient or proxy decide for DNR following procedure is done when the patient
experiences cardio pulmonary arrest or respiratory arrest:

WILL suction the airway, administer oxygen, position for comfort, splint or
immobilize, control bleeding, provide pain medication, provide emotional support, and
contact other appropriate health care providers, and

WILL NOT administer chest compressions, insert an artificial airway, administer

resuscitative drugs, defibrillate or cardiovert, provide respiratory assistance (other than
suctioning the airway and administering oxygen), initiate resuscitative IV, or initiate
cardiac monitoring.

What are the possible reasons for physician to indorse the DNR?
The Patient request it.
The patient is not expected to live more than a year.
The patient has a serious and irreversible illness or disabling condition.
The patient has suffered irreversible loss of consciousness.
The patient had, or is likely to have, a cardiopulmonary arrest.
The physician has reason to believe the patient would not want CPR
Advance directives aim to honor individual autonomy, respect individual choice, and prevent
situations in which a patient is given treatments he or she would not have wanted. Because they
involve critical decisions about end of life care, ethical concerns have been expressed about their
use. These concerns include the following:
Advance directives may improperly influence health care providers to limit care leading to
under treatment.
A person frightened of becoming disabled or incapacitated may use advance directives to limit
treatmentwhen in reality a person cannot know in advance his or her ability to cope and adapt
to living with a disability.
Advance directives are time consuming for health professionals, and may not be useful if a
medical treatment decision requires an immediate answereven if a healthcare decision-maker
has been named.

Possible Effect of Advance Directives on Patients and Families

Advance directives may provide patients with peace of mind. Patients may be comforted
knowing that difficult decisionsabout procedures and treatments that they do or do not want
have already been made should they become unable to communicate. Further, they may gain
peace from knowing that the advance directive may prevent or minimize disagreement among
loved ones.

Physician Assisted Suicide

With physician assisted suicide, a doctor provides a patient with a prescription for drugs that a
patient could use to end his or her life.
The main distinction between physician assisted suicide and active euthanasia is that the doctor
is not the person physically administering the drugs. Physician assisted suicide is only
contemplated byand would only be considered as an option forpatients who are conscious
and capable of making their own decisions.
In contrast to active euthanasia, where a physician would end a persons life, assisted suicide is
an active choice by a person to end his or her own life. For some people, physician assisted
suicide seems a viable option that would allow the opportunity to forgo suffering and loss of
control. The primary ethical arguments offered to justify physician assisted suicide are that it:
Allows autonomy and self-empowerment of the patient.
Shows compassion and mercy.
Gives freedom from suffering.
Factors that influence physicians' attitudes towards physician-assisted suicide
Area of specialization and experience with terminally ill patients

Physicians who identify themselves as palliative care professionals are less willing to
support the practice of physician-assisted suicide and euthanasia.

In a questionnaire to 938 physicians in the State of Washington, USA, hematologists and

oncologists, who are the physicians with the most experience in dealing with terminally
ill patients, were most likely to oppose euthanasia and assisted suicide, and psychiatrists,
who had the least contact with terminally ill patients, were most likely to be supportive of
these practices.

Previous engagement in euthanasia and assisted suicide

Those who have previously performed euthanasia or assisted suicide are more likely to view
these as ethical practices.[ The older the physician the less likely he or she is to have performed
euthanasia or assisted suicide."For every additional year of age the odds of having engaged in
euthanasia decrease by 3.1%" Therefore age correlates with attitudes to these practices.

Other factors

A study conducted in Australia reported that those who are the most likely to oppose
physician-assisted suicide and euthanasia are older, western-educated, Catholic and
female.

Historically, suicide has been considered by many to be an immoral act in any form. People who
think that suicide is a moral option may still object to physician assisted suicide because it
requires physician involvement. They would argue that physicians are taught to treat illness and
extend life, so physician-assisted suicide goes against their training.
Hippocratic Oath
Physician-assisted suicide is contrary to the original Hippocratic Oath that has been in use since
the 5th Century BC, stating "I will give no deadly medicine to anyone if asked, nor suggest any
such counsel".
Risk to public safety
There is a danger that a right to die may become a responsibility to die making already
vulnerable people even more vulnerable."
Professional organization perspectives on participation: Both the American Medical
Association and the ANA (2010b) state that clinicians participation in assisted suicide is
incompatible with professional role integrity and violates the social contract the professions have
with society. Physician-assisted suicide is essentially discordant with the physicians role as
healer, would be problematic to control, and would pose grave societal risks. Instead of joining
in assisted suicide, physicians must aggressively answer to the necessities of patients at the end
of life (AMA, 1996). Both have vowed to honor the sanctity of life and their duty not to inflict
harm (nonmaleficence).

Prolonging life issues

Decisions to commence life prolonging treatment

Two ethical principles involved:

Justice - the health professionals needs to consider the individual case in light of
available resources.
Autonomy the individuals autonomous may be overridden on three grounds; first, if the
health team considers the treatment will be full in the sense of not achieving the desired
physiological change; second, if the treatment involves pain disproportionate to the hoped
benefit; third, if a member of the health care team has a conscientious objection to the
required treatment.

Ordinary versus Extraordinary Measures

Ordinary measures are medication or treatments which is directly available and can be
applied without incurring severe pain, cost or other inconveniences,
This kind of treatment therefore opens the possibility of cure for the patient the word
hope give us an idea to this kind of treatment for the patient.
Extraordinary measures are medication or treatments which cannot be applied without
incurring severe pain, cost or other inconveniences.
This kind of treatment closes all the capacity and means of the physician to cure the
patient but there is a possibility open for other new treatment thats why patient under this
treatment is under experimentation and at the same time just assisting the patient by giving
him care and nutrients to sustain.
A treatment or life-sustaining measure can be extraordinary because it is too painful, frightening,
hazardous or disruptive for the patient, or because it is financially too burdensome to the patient,
family, hospital or health service. A treatment can also be too burdensome in other ways to those
who are caring for the patient -- for example, it can take up time or use facilities which are
urgently needed by patients who would benefit more.
A treatment can also be extraordinary because it is simply futile. For example, those who are
dying of one illness have no obligation to accept treatment for a second life-threatening condition
which is at a less advanced stage. Often, however, a treatment will be extraordinary not because
that treatment will be altogether futile, but because its burdens will be disproportionate to the
benefits it will bring.
'Quality of life' - judging if the patient's life will be worthwhile

Children Who are Dying

When children suffer a terminal illness, the childs family, community, and the healthcare system
often rally to provide support and care. Dying children and their parents may face the same
ethical issues at the end of life as adults do, such as treatment options and resuscitation decisions.
However, there are also unique ethical issues specific to children.
Family Members in Conflict

Conflicting opinions may arise among family members when making health care decisions for
children:
Parents can disagree with each otherDivorced parents may have different values or married
parents may find that they are in conflict over the best course of action.
Parents and other family members can disagreeGrandparents actively involved in child
raising may differ with parents.
Parents and child may not agreeThese conflicts can arise at any age and may be particularly
disheartening.
Including the Child in Decisions
Many professionals who work with dying children believe that theyparticularly adolescents
should be included in healthcare decisions. Involving children in care decisions by allowing them
to ask questions raise fears and concerns, and express their opinions to the extent that they are
able can prove invaluable in easing of tension between children, parents, and medical
professionals

Ethical Issues in Human Organ/ Tissue Transplantation

An organ transplant is a surgical operation where a failing or damaged organ in the human
body is removed and replaced with a new one.
A graft is similar to a transplant. It is the process of removing tissue from one part of a persons
body (or another persons body) and surgically reimplanting it to replace or compensate for
damaged tissue. Grafting is different from transplantation because it does not remove and replace
an entire organ, but rather only a portion.
Homograft is the transplantation of an organ from one individual to anoter of the same species,
e.g. from one being to another, or from one dog to another dog.
Heterograft is the transplantation of organs between individuals of different species, e.g., from
animals to man or from dogs to monkeys.
Isograft is transplantation between two genetically-identical persons-for example, between two
identical twins.
Republic Act No. 7170 "Organ Donation Act of 1991".

Drawbacks to becoming a living donor may include:

Health consequences: Pain, discomfort, infection, bleeding and potential future health
complications are all possible
Psychological consequences: Family pressure, guilt or resentment
Pressure: Family members may feel pressured to donate when they have a sick family member
or loved one

No donor advocate: While the patients have advocates, like the transplant surgeon or medical
team (who are there to advise the patient and work in favor of his or her best interests) donors do
not have such an advocate and can be faced with an overwhelming and complicated process with
no one to turn to for guidance or advice

1. Ethical Issues Regarding the Donor

a) From the Deceased
In general it is seen as praiseworthy to will one's body or parts of one's body for the
benefit of others after one's death.
b) From Living Persons (Adults, Mentally Disabled, Minors)
Principle of totality states that a person cannot justify the removal of a healthy organ and incur
the risk of future health problems when his own life is not in danger, as in the case of a person
sacrificing a healthy kidney to donate to a person in need. Such surgery, they held, entails an
unnecessary mutilation of the body and is thereby immoral.
c) From Anencephalic Infants - If born alive they die within a few days, weeks or months
d) From Human Fetuses- treating Parkinsons disease
Concerns the use of organs or tissues from aborted children (such as those murdered
through partial birth abortion procedures
2. Ethical Issues Regarding the Recipient considers religion and safety
3. Ethical Issues Regarding Allocation of Limited Resources
a) Criteria for Selection considers who will likely benefit more from receiving a
transplant.
b) Using Animals human experimentations
First addressed by Pope Pius XII in 1956, the Church maintains that such transplants are morally
acceptable on three conditions: (1) the transplanted organ does not impair the integrity of the
genetic or psychological identity of the recipient, (2) the transplant has a proven biological
record of possible success, and (3) the transplant does not involve inordinate risk for the
recipient.
c) Artificial Substitutes for Tissues and Organs - includes false teeth, artificial limbs and
joints, hearing aids, synthetic lenses, pacemakers, mechanical and synthetic heart valves,
genetically engineered insulin and growth hormone, and renal dialysis.
d) High Costs, Universality and Justice
4. Ethical Issues Regarding Procurement of Organs and Tissues
a) Buying and Selling Human Organs and Tissues
The selling of an organ violates the dignity of the human being, eliminates the criterion of
true charity for making such a donation, and promotes a market system which benefits
only those who can pay, again violating genuine charity. Pope John Paul II has repeatedly
underscored this teaching: A transplant, even a simple blood transfusion, is not like other

operations. It must not be separated from the donors act of self-giving, from the love that
gives life
b) Media Publicity publicizing their need through the media. Treating body as an
object is to violate the dignity of the human person.
c) Types of Consent patients who were not able to make consent prior to
incapacitation.
d) Fears, Confusion and the Need for Education
According to a study in US (1992), The two most common reasons given for not
permitting organ donation were (1) they might do something to me before I am really
dead; (2) doctors might hasten my death
Sources:
Books:
Kappel, Klemens (2001) University Of Copenhagen, http://www.scribd.com/doc/77339548/TheMorality-of-Euthanasia
Timbreza, Florentino (2007) Bioethics and Moral Decisions
Ethical Issues in Health Care (2003) first edition, Educational Publishing House
Websites:
http://en.wikipedia.org/wiki/Legality_of_euthanasia
http://Nursevillage.com - Keep In Touch - The Moral Issue of Dying with Dignity A Nurses
Role in Assisted Suicide.htm
End of Life Care: An Ethical Overview (2005), University of Minnesotas Center for Bioethics,
http://www.ahc.umn.edu/img/assets/26104/End_of_Life.pdf
American Nurses Association Position Statement (April 24, 2013) Euthanasia, Assisted Suicide,
and Aid in Dying, http://www.nursingworld.org/MainMenuCategories/EthicsStandards/EthicsPosition-Statements/Euthanasia-Assisted-Suicide-and-Aid-in-Dying.pdf
http://en.wikipedia.org/wiki/Assisted_suicide
http://www.lifeissues.net/writers/mis/mis_01prolonginglife.html
http://www.scribd.com/doc/39713606/Morality-on-Do-Not-Resuscitate-Order-2
http://www.ualberta.ca/~pflaman/organtr.htm
http://en.wikipedia.org/wiki/Right_to_life
http://en.wikipedia.org/wiki/Right_to_die
http://www.lawphil.net/statutes/repacts/ra1992/ra_7170_1992.html