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Euthanasia: A Question of Ethics

Euthanasia: A Question of Ethics
Euthanasia is one of the most acute and uncomfortable contemporary
problems in medical ethics. Is Euthanasia Ethical? The case for euthanasia
rests on one main fundamental moral principle: mercy.

It is not a new issue; euthanasia has been discussed-and practised-in
both Eastern and Western cultures from the earliest historical times to the
present. But because of medicine’s new technological capacities to extend life,
the problem is much more pressing than it has in the past, and both the
discussion and practice of euthanasia are more widespread.

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Euthanasia is a way of granting mercy-both by direct killing and by
letting the person die. This principle of mercy establishes two component
duties: 1. the duty not to cause further pain or suffering; and 2. the duty to
act to end pain or suffering already occurring. Under the first of these, for a
physician or other caregiver to extend mercy to a suffering patient may mean to
refrain from procedures that cause further suffering-provided, of course, that
the treatment offers the patient no overriding benefits. The physician must
refrain from ordering painful tests, therapies, or surgical procedures when they
cannot alleviate suffering or contribute to a patient’s improvement or cure.

Perhaps the most familiar contemporary medical example is the treatment of burn
victims when survival is unprecedented; if with the treatments or without them
the chances of the patient’s survival is nil, mercy requires the physician not
to impose the debridement treatments , which are excruciatingly painful, when
they can provide the patient no benefit at all. Although the demands of mercy
in burn contexts have become fairly well recognized in recent years, other
practises that the principles of mercy would rule out remain common. For
instance, repeated cardiac resuscitation is sometimes performed even though a
patient’s survival is highly unlikely; although patients in arrest are
unconscious at the time of resuscitation, it can be a brutal procedure, and if
the patient regains consciousness, its aftermath can involve considerable pain.

Patients are sometimes subjected to continued unproductive, painful treatment to
complete a research protocol, to train student physician, to protect the
physician or hospital from legal action, or to appease the emotional needs of
family members; although in some specific cases such practises may be justified
on other grounds, in general they are prohibited by the principle of mercy.

Weather a painful test or therapy will actually contribute to some overriding
benefits for him or her, they should not be done.

In many such cases, the patient will die whether or not the treatments
are performed. In some cases, however, the principle of mercy may also demand
withholding treatment that could extend the patient’s life if the treatment is
itself painful or discomforting and there is very little or no possibility that
it will provide life that is pain-free or offers the possibility of other
important goods. For instance, to provide respiratory support for patient in
the final, irreversible stages of a deteriorative disease may extend his life
but will mean permeant dependence and incapacitation; though some patients may
take continuing existence to make possible other important goods, for some
patients continued treatment means pointless imposition of continuous pain.

The principle of mercy may also demand letting die in a still stronger
sense. Under its second component, the principle asserts a duty to act to end
suffering that is already occurring. Medicine already honours this duty through
its various techniques of pain management, including physiological means like
narcotics, nerve blocks, acupuncture, and neurosurgery. In some cases pain or
suffering is severe but cannot be effectively controlled, at least as long as
the patient remains sentient at all. Classical examples include tumours of the
throat, tumours of the brain or bone, and so on. Severe nausea, vomiting, and
exhaustion may increase the patient’s misery. In these cases, continuing life-
or at least continuing consciousness- may mean continuing pain. Mercy’s demand
for euthanasia takes place here: mercy demands that the pain, even if with it
the life, be brought to an end.

Ending the pain, though with it the life, may be accomplished through
what is usually called “passive euthanasia”, withholding or withdrawing
treatment that could prolong life. In the most indirect of these cases, the
patient is simply not given treatment that might extend his or her life. For
example, radiation therapy in advanced cancer. In the more direct cases, life-
saving treatment is deliberately withheld in the face of an immediate, lethal
threat-for instance, antibiotics are withheld from cancer patient when an
overwhelming infection develops, since through either the cancer or the
infection will kill the patient, the infection will kill them sooner and in a
much gentler way. In all of the passive euthanasia cases, the patient’s life
could be extended;it is mercy that demands that he or she be allowed to die.

The second component of the mercy principle may also demand the easing
of pain by means more direct than mere allowing to die; it may require killing.

This usually is called “active euthanasia. In passive euthanasia, treatment is
withheld that could support failing bodily functions, either in warding off
external threats or in performing its own processes; active euthanasia, in
contrast, involves the direct interruption of ongoing bodily processes that
otherwise would have been able to sustain life. However, although it may be
possible to draw a conceptual distinction between passive and active euthanasia,
this provides no warrant for the ubiquitous view that killing is morally worse
than letting die. Nor does it support the view that withdrawing treatment is
worse than withholding it. If the patient’s condition is so tragic that
continuing life brings only pain, and there is no other way to relieve the pain
than by death, then the more merciful act is not one that merely removes support
for bodily processes and waits for eventual death to ensue; rather. it is one
that brings the pain- and the patient’s life- to an end now. If there are also
grounds on which it is merciful not to prolong life, then there are grounds on
which it is merciful to terminate it at once. The easy overdose, the lethal
injection, are what mercy demands when no other means will bring relief.

Pain is a thing of the medical past, and euthanasia is no longer
necessary, though it may have been, to relieve pain. Given modern medical
technology and recent remarkable advances in pain management, the sufferings of
the morally wounded and dying can be relieved by less dramatic means. For
instance, many once-feared, painful diseases-tetanus, rabies, leprosy,
tuberculosis-are now preventable or treatable. Improvements in battlefield
first aid and transport of the wounded have been so great that the military coup
de grace is now officially obsolete. We no longer speak of “moral agony” and
“death throes” as the probable last scenes of life. Particularly impressive are
the huge advances under the hospice program in the amelioration of both the
physical and emotional pain of terminal illness, and our culturewide fears of
pain in terminal cancer are no longer justified: cancer pain, when it occurs,
can now be controlled in virtually all cases. We can now end the pain without
also ending the life.

It is flatly incorrect to say that all pain, including pain in terminal
illness, is or can be controlled. Some people still die in unspeakable agony.

With superlative care, many kinds of pain can indeed be reduced in many patients,
and adequate control of pain in terminal illness is often quite easy to achieve.

Nevertheless, complete, universal, fully reliable pain control is a myth. Pain
is not yet a “thing of the past”, nor are many associated kinds of physical
distress. Some kinds of conditions, such as difficulty in swallowing, are still
difficult to relieve without introducing other discomforting limitations. Some
kinds of pain are resistant to medication, as in elevated intracranial pressure
or bone metatases and fractures. For some patients, narcotic drugs are
dysphoric. Pain and distress may be increased by nausea, vomiting, itching,
constipation, dry mouth, abscesses and decubitus ulcers that do not heal,
weakness, breathing difficulties, and offensive smells. Severe respiratory
insufficiency may mean an agonizing final few hours. Even a patient receiving
the most advanced and sympathetic medical attention may still experience
episodes of pain, perhaps altering with consciousness, as his or her condition
deteriorates and the physician attempts to adjust schedules and dosages of pain
medication. Many dying patients, including half of all terminal cancer patients,
have little to no pain, but there are still cases in which pain management is
difficult. Finally, there are cases in which pain control is theoretically
possible but for various reasons does not occur. Some deaths take place in
remote locations where there are no pain-relieving resources. Some patients are
unable to communicate the nature or extent of their pain. And some institutions
and institutional personnel who have the capacity to control pain do not do so,
whether from inattention, malevence, fears of addiction, or divergent priorities
in resources.

In all of these cases, of course, the patient can be sedated into
unconsciousness; this does indeed end the pain. But in respect of the patient’s
experience, this is tantamount to causing death: the patient has no further
conscious experience and thus can achieve no goods, experience no significant
communication, satisfy no goals. Furthermore, adequate sedation, by depressing
respiratory function, may hasten death. Though it is always technically
possible to achieve relief from pain, at least when the appropriate resources
are available, the price may be functionally and practically equivalent, at
least from the patient’s point of view, to death. And this, of course, is just
what the issue of euthanasia is about.
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