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Medical Ethics and End-of-Life Decisions

Morality depends on the cognitive dimension of our behavior or our thought processes – the way we conceptualize right or wrong and make decisions and reason about how we should behave. Moral issues concern both behavior and conduct. They arise when people are faced with such questions as: “What should I do (or not do)?” “How should I act?” “What kind of person should I be?”

Ethics differs from morals and morality in that ethics deals with standards of goodness or rightness whereas morals refer to a system of beliefs about what is considered to be right or wrong behavior. One example is the classic “Hippocratic Oath” taken by all doctors, which has been interpreted over the years to include the promise to “first, do no harm.” The expression to “do no harm” is not in the Oath itself but the following statement: To practice and prescribe to the best of my ability for the good of my patients, and try to avoid harming them.” This is the statement of the moral obligation of physicians.

The ethical translation of the “harm” principle is: “I will follow the system of regimen which, according to my ability and judgment, I consider for the benefit of my patients and abstain from whatever is deleterious and mischievous.” In this sense, one’s moral belief tracks private behavior whereas the ethical has a public dimension to it.

The basis for ethics must be morals, not the other way around. The notion that doctors must do no harm refers to the intrinsic care doctors have for the well-being of their patients as an example of something moral in the context of medicine.  It implies that doctors will act in a way that treats their patients’ health and welfare as an end itself or a good in itself (i.e., to maintain or improve the health of patients) -- not as a means to an end such as to perform medically unnecessary procedures to earn greater fees and then rationalize it by saying it is for the good of the patient.

Putting aside the question of whether the Hippocratic Oath is relevant to the practice of medicine today, questions about the application of the “harm” ethical standard to real-life situations, such as physician-assisted suicide, illustrates the challenge of determining right from wrong when the interests of a patient and the beliefs of a physician conflict. Here is an ethical dilemma faced by physicians that illustrates the difficulty of applying the “harm” moral principle.

Your mother is dying from pancreatic cancer. Her physician has informed her that she will likely die within six months. Your mother discusses the matter with your dad and your two brothers. The family decides to ask the physician to prescribe a drug to help your mom escape the unbearable suffering at the end of her life. The family explains the situation to the physician who expresses his concerns and they all set a meeting for later that day to explore the matter in full.

Prior to the passage of the Oregon Death with Dignity Act in 1996, the term most often used when a physician provided the means for a patient’s death was “physician-assisted suicide (PAS).” However, recent laws use PAD since it reflects the requirement that eligible persons must be competent enough to make an informed decision and have a life expectancy of about six months or less. Six states and the District of Columbia have PAD laws known as “Death with Dignity” or “End-of-Life Options.” PDA

PAD refers to a practice in which the physician provides a competent, terminally ill patient with a prescription for a lethal dose of medication, upon the patient’s request, which the patient intends to use to end his or her own life. In PAD, the patient must self-administer the medications. The aid-in dying refers to the physician providing the medications, but the patient decides where and when to ingest the lethal medication. PAD differs from “euthanasia” where a third party administers medication or acts directly to end the patient’s life. Euthanasia is illegal in every state.

My problem with legislating right-to-die issues is to ask the basic question: Can we (should we) legislate morality? There are many moral concerns for the physician? Here are a few.

  1. Does a patient have a “right to die”?
  2. Justice requires that we “treat like cases alike.” But, how is this possible in PAD cases that are personal?
  3. What are the potential harms and benefits to society of assisting in a patient’s death?
  4. What does it mean to be a compassionate physician?

It’s time for us to fully explore these issues given our aging society. Thousands of people may face these issues in the near term. Putting aside the legal issues, the ethical implications of allowing a physician to assist in the death of a patient raises moral issues that can no longer be ignored.

Blog posted on June 14, 2017 by Steve Mintz, Professor Emeritus, Cal Poly San Luis Obispo. Steve blogs under the pseudonym, Ethics Sage.