Ethical Issues in Terminal Health Care

Part One: Issues and Their Implications

by Ed Newman

Medical science has brought remarkable changes to our lives. Because of advances in medical technology, more people live longer, and more productively, than any generation in history.

Unfortunately, these advances have created problems as well. The longer people live, the more likely they are to encounter chronic disease that requires long-term health care. Medical advances have also brought economic consequences -- these new technologies have a price tag! Most important, these advances have created ethical dilemmas that no generation of doctors has ever had to face. New life-sustaining techniques and practices are forcing hospitals to ask questions that never needed to be asked before. Foremost of these is the question, "How far do we go to save a life?"

Other questions challenge the very notion of what it means to be a doctor. A doctor's commitment has traditionally been to sustain life, to comfort and to heal. Today, though, physcians are able to sustain lives which have no hope of ever again being meaningful, which brings us to the question: when suffering is immeasurable, and a patient's condition terminal, should doctors be permitted to end a patient's life? Syndromes like persistent vegetative state and the immense suffering caused by prolonged cancers have many people, including some doctors, wondering if it wouldn't be more humane for physicians to do more than merely withdraw treatment, but to actually assist in hastening death.

The purpose of this series of articles is to explore these questions, to discover their implications and to help foster a clearer understanding of the ethical issues surrounding terminal health care in our technologically advanced society.
The Issue of the 1990's

One of the most hotly debated news topics in 1991 was the subject of euthanasia, a subject that many believe will become one of the key issues of the 1990's. Dr. Arthur Caplan, Ph.D., director of the Center for Biomedical Ethics at the University of Minnesota, noted that this is not a suddenly new topic, but simply one that has become more public.

"It broke out into the public because of several events," Dr. Caplan said, "foremost of these being the intentional effort to put it on the political agenda by people like Betty Rollin (author of Last Wish), Derek Humphry (founder of The Hemlock Society), and most recently, Dr. Jack Kervorkian. There has been a movement to shift the debate to a public one rather than one among doctors."

According to Caplan another reason euthanasia is an issue today is that many people have been disturbed by the prospect of being trapped by technology. Said Caplan, "You see some of these cases where people can't get treatments stopped, and they want the right to end it, so they don't have to wind up like a Cruzan." (Nancy Cruzan died eleven days after a judge authorized her parents to order removal of a feeding tube that had kept her alive in a persistent vegetative state for more than six years.)

Tom Elliott, oncologist at the Duluth Clinic and national lecturer in pain management among the terminally ill, offered two additional reasons why interest in euthanasia among lay people has been increasing. "Number one," he said, "because people want to have more control over their lives and perceive that they have lost some control because of technology that may have taken something away from them, and they are trying to get back some of their personal autonomy.

"I think also it's occurring because there is a perceived and real lack of high quality symptom management in the terminally ill," Dr. Elliott said. "I think the public knows that, and knows that there is inadequate pain relief for the terminally ill, so that some of them are saying 'If you can't relieve my pain, at least give me the right to end my life.'"

In this Dr. Caplan agrees. "I think pain control is a problem, and too many doctors don't use it adequately in terminally ill patients," he said. "It's crazy, but it happens, and that frightens people."

Health Care at a Crossroads
"When you prolong the life of a cancer patient, the natural history of the disease advances and you see complications you did not see before," says Dr. David Camenga, a Neurosurgeon at the Duluth Clinic. Camenga uses a term for these complications: "diseases of medical progress."
According to ethicist Carolyn Schmidt, Professor Emeritus at the College of St. Scholastica, "I think this age might be called The Age of the Tyranny of Technology. Because technologies exist, there seems to be -- in the medical profession at least -- an assumption that the technologies must be used.

"We are coming now to see the terrible dilemmas that the overuse of technologies have brought to us," Ms. Schmidt said. "But we are using what I feel are the wrong ways to address this." She believes there need to be more questions asked about when or whether to use the new machines and techniques in the first place. She also believes that medical science and public policy should understand that when a technology is being used, it can be discontinued under the principle of the Benefit/Burden concept. When the burden to the total well-being of the patient outweighs the benefit, the treatment becomes senseless. She pointed out that morally, extraordinary means of treatment need not be used in the first place.

Dr. Caplan adds this perspective: "It is not the technologies that are to blame, but rather, the failure to articulate clear policies about how to use them, when to use them, what the goals and purposes are. After all, technolgy doesn't do anything. Somebody has to turn it on and turn it off."

Here's a common example of how the use of life support technologies can create an ethical dilemma for the families of patients and the physicians who treat them. Often, in the transfer of a critical patient from a nursing home to a hospital, the nursing home will send the DNR Order (see Sidebar on DNR Orders) but the transport team, being dedicated to the delivery of patients to the hospital, may often resuscitate the patient. By the time they get to the hospital the person is on a ventilator, which results in the ethical dilemma of whether to remove life support once it has been initiated. Noted Ms. Schmidt, "And everybody is afraid to remove it for fear of a lawsuit."

"I think that's a problem," said Dr. Caplan, "and my response to that is that we have to get a better understanding of when to stop things. We also need to put in rules that say you may not start something, any technology or treatment, without describing when it is you are going to stop it. Because after all, everything that's done has to be stopped. So you should have just as much attentiveness to the stopping rules as you do the starting rules. That isn't the case right now. There's a sort of assymetry. Once things are put in it becomes that much harder to get them taken away. It's partly psychological. {We feel} if I remove this, she's going to die and I don't want to be a part of that."

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Any information in this article pertaining to legal or medical matters is not to be construed as professional advice. Copyrights remain the property of the authors.

Original versions of these articles originally appeared in The Senior Reporter in the spring of 1992.


Part One: Issues and Their Implications
Part Two: Ethics Committees
Part Three: Local Perpsectives on the Right-to-Die Debate
Part Four: Patients Have Rights, But Doctors Have Rights, Too
Part Five:
The Pros and Cons of Physician Assisted Suicide

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