FEU-NRMF

INSTITUTE OF MEDICINE Euthanasia & Physician Assisted Suicide

Bioethics 2 • Euthanasia is killing on request and is defined as a doctor
Dr. Maria Fidelis C. Manalo, MSc intentionally killing a person by the administration of drugs, at

that person’s voluntary and competent request.
ETHICAL DECISION-MAKING IN END-OF-LIFE CARE
• Physician-assisted suicide is defined as a doctor intentionally

helping a person to commit suicide by providing drugs for self-
Sanctity of Life
administration, at that person’s voluntary and competent
You shall not kill.
request.
You have heard that it was said to the men of old, "You shall not kill:

and whoever kills shall be liable to judgment." But I say to you that
Foregoing Extraordinary Means to Prolong the Life of a Dying
every one who is angry with his brother shall be liable to judgment.
Patient
• "Human life is sacred because from its beginning it involves the
• Foregoing extraordinary means to sustain life is different from
creative action of God and it remains for ever in a special
euthanasia on several main points:
relationship with the Creator, who is its sole end.
Ø Unlike euthanasia, foregoing extraordinary means is not
• God alone is the Lord of life from its beginning until its end: no
intended to cause death.
one can under any circumstance claim for himself the right
Ø The death that follows from foregoing extraordinary
directly to destroy an innocent human being.”
means was not induces or directly cause. The death simply
Catechism of the Catholic Church, 2258
follows from the natural process of dying that is no longer

postponed by extraordinary means.
Stewardship of Life
• Discontinuing medical procedures that are burdensome,
• In this view, we are stewards, not owners, of our own bodies
dangerous, extraordinary, or disproportionate to the expected
and are accountable to God for the life that has been given to
outcome can be legitimate.
us.
• It is the refusal of “over-zealous” treatment.

Human life as a value • Here, one does not will to cause death; one’s inability to impede
it is merely accepted.
• Life, however, is not an absolute value.
• The decisions should be made by the patient if he is competent
• The Christian understanding of life’s meaning and purpose is
and able or, if not, by those legally entitled to act for the patient,
founded on a belief in the resurrection of Christ and the hope
whose reasonable will and legitimate interests must always be
of an afterlife.
respected.
• We have a duty to preserve our life and to use it for the glory of
• Determining whether a treatment is ordinary or extraordinary
God, but the duty to preserve life is not absolute.
depends upon the balance between two sets of factors.

Ø On one hand, we have to consider the physical,
Care for the Sick
psychological, economic and other harm which a given
• Those whose lives are diminished or weakened deserve special
modality of treatment is expected to cause, first of all, to a
respect.
patient, but also to his or her relatives and friends as well
• Sick or handicapped persons should be helped to lead lives as
as to society.
normal as possible.
Ø On the other hand, we have to take into account the
Catechism of the Catholic Church, 2276
degree of probability, if any, first of all, that the patient will

be cured or will be able, for a significant period of time, to
Euthanasia
live on under humanizing conditions.
• Consists of an act or omission which, of itself or by intention,
• If the good outweighs the harm, then it can be reasonably
causes death in order to eliminate suffering
affirmed that the means is morally ordinary (“proportionate”).
• Constitutes a murder gravely contrary to the dignity of human
If the harm outweighs the good, then disproportion probably
person and to the respect due to the living God, his Creator.
exists and means is probably morally extraordinary.
• The death cause by euthanasia is not part of the natural process
• Extraordinary means usually refer to highly specialized,
of dying of a terminally ill person.
physically difficult, psychologically draining or very expensive
• Whatever its motives and means, direct euthanasia consists in measures used in order to delay the imminent death and
putting an end to the lives of handicapped, sick, or dying prolong the life of the dying patient.
persons. It is morally unacceptable.
• These extraordinary means no longer correspond to the real
Catechism of the Catholic Church, 2277
situation of the patient, either because they are by now

disproportionate to any expected results or because they
Medicalized Killing
impose an excessive burden on the patient and his family.
• Medicalized killing of a person without the person’s consent,
whether non-voluntary (where the person is unable to consent) Care for the Terminally-ill
or involuntary (against the person’s will), is not euthanasia: it is
• Even if death is thought imminent, the ordinary care owed to a
murder.
sick person cannot be legitimately interrupted.
• Hence, euthanasia can be voluntary only.
• The use of painkillers to alleviate the sufferings of the dying,
Materstvedt et al, Palliative Medicine 2003
even at the risk of shortening their days, can be morally in

conformity with human dignity if death is not willed as either an

end or a means, but only foreseen and tolerated as inevitable

• Palliative care is a special form of disinterested charity. As such

it should be encouraged.



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Palliative Sedation vs. Euthanasia Advance Directives
• In terminal or palliative sedation of those imminently dying: • Legal documents, such as the living will, durable power of
Ø Intention - to relieve intolerable suffering attorney and health care proxy, which allow people to convey
Ø Procedure - to use a sedating drug for symptom control their decisions about end-of-life care ahead of time.
Ø Outcome - alleviation of distress • Provide a way for patients to communicate their wishes to
• In euthanasia: family, friends, and health care professionals and to avoid
Ø Intention – to kill the patient confusion later on, should they become unable to do so.
Ø Procedure – to administer a lethal drug • Ideally, the process of discussing and writing advance directives
Ø Outcome – immediate death should be ongoing, rather than a single event.
• Advance directives can be modified as a patient’s situation
Palliative Sedation changes.
• In palliative care, mild sedation may be used therapeutically but • Even after advance directives have been signed, patients can
in this situation it does not adversely affect the patient’s change their minds at any time.
conscious level or ability to communicate.
• The use of heavy sedation (which leads to the patient becoming Importance of Advance Directives
unconscious) may sometimes be necessary to achieve identified • Complex choices about end-of-life care are difficult even when
therapeutic goals. people are well. If a person is seriously ill, these decisions can
• However, the level of sedation must be reviewed on a regular seem overwhelming.
basis and in general used only temporarily. • But patients should keep in mind that avoiding these decisions
• It is important that the patient is regularly monitored. when they are well will only place a heavier burden on them
and their loved ones later on.
The Use of Painkillers That May Shorten the Life of a Terminally-ill • Communicating wishes about end-of-life care will ensure that
Patient people with life-limiting illness face the end of their lives with
• It is licit to relieve pain by narcotics, even when the result is dignity and with the same values by which they have lived.
decreased consciousness and a shortening of life, "if no other
means exist, and if, in the given circumstances, this does not Living Will
prevent the carrying out of other religious and moral duties." • A set of instructions documenting a person's wishes about
• In such a case, death is not willed or sought, even though for medical care intended to sustain life.
reasonable motives one runs the risk of it: there is simply a • It is used if a patient becomes terminally ill, incapacitated, or
desire to ease pain effectively by using the analgesics which unable to communicate or make decisions.
medicine provides. (Evangelium Vitae, 65) • Everyone has the right to accept or refuse medical care.
• It protects the patient's rights and removes the burden for
ADVANCE DIRECTIVES AND END-OF-LIFE DECISIONS making decisions from family, friends, and physicians.
• Types of life-sustaining care that should be taken into
What rights do patients have regarding their medical treatment? consideration when drafting a living will:
• Patients are entitled to complete information about their illness Ø Use of life-sustaining equipment (dialysis machines,
and how it may affect their lives, and they have the right to ventilators, and respirators)
share or withhold that information from others. Ø "Do not resuscitate" orders; that is, instructions not to use
• Patients should also be informed about any procedures and CPR if breathing or heartbeat stops
treatments that are planned, the benefits and risks, and any Ø Artificial hydration and nutrition (tube feeding)
alternatives that may be available. Ø Withholding of food and fluids
• Patients have the right to make decisions about their own Ø Palliative/comfort care
treatment. These decisions may change over time. Ø Organ and tissue donation
• In the face of worsening disease, some patients may want to try • It is also important to understand that a decision not to receive
every available drug or treatment in the hope that something "aggressive medical treatment" is not the same as withholding
will be effective. all medical care.
• Other patients may choose to forgo aggressive medical • A patient can still receive antibiotics, nutrition, pain medication,
treatment. radiation therapy, and other interventions when the goal of
• Many patients turn to family members, friends, or caregivers treatment becomes comfort rather than cure.
for advice. But it is the patient’s decision how much or how little o This is called palliative care, and its primary focus is
treatment to have. helping the patient remain as comfortable as possible.
• Sometimes a patient is unable to make this decision, due to • Patients can change their minds and ask to resume more
severe illness or a change in mental condition. That is why it is aggressive treatment.
important for people with life-limiting illnesses to make their • If the type of treatment a patient would like to receive changes,
wishes known in advance. however, it is important to be aware that such a decision may
raise insurance issues that will need to be explored with the
End-of-life Care patient's health care plan.
• A general term that refers to the medical and psychosocial care • Any changes in the type of treatment a patient wants to receive
given in the advanced or terminal stages of illness. should be reflected in the patient's living will.
• Once a living will have been drawn up, patients may want to talk
about their decisions with the people who matter most to
them, explaining the values underlying their decisions.

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• In the US, most states require that the document be witnessed. Withholding, Withdrawing Life-Sustaining Treatment
• Then it is advisable to make copies of the document, place the RICHARD J. ACKERMANN, M.D.
Am Fam Physician. 2000 Oct 1;62(7):1555-1560.
original in a safe, accessible place, and give copies to the
o Any life-sustaining treatment…
patient's doctor, hospital, and next of kin.
Ø Resuscitation (CPR)
• Patients may also want to consider keeping a card in their wallet
Ø Elective intubation, mechanical ventilation
declaring that they have a living will and where it can be found.
Ø Surgery

Ø Dialysis, Hemofiltration
History of the “Living Will”
Ø Blood transfusions, blood products
• The "living will" was originally invented in 1967 by two groups,
Ø Diagnostic tests
the Euthanasia Society of America and Euthanasia Education
Ø Artificial nutrition (parenteral or enteral) or hydration (IVF)
Council, and was touted as a first step in gaining public
Ø Antibiotics
acceptance of euthanasia.
Ø Vasopressors
• These groups had been struggling for years to get "mercy-
Ø Future hospital, ICU admissions
killing" bills (which would allow doctors to give disabled or dying
...aimed at maintaining organ function that only prolong death
patients lethal overdoses) passed in various state legislatures.
may be withdrawn or withheld


Resisting the new “Death Ethics”
o 8-step protocol to discuss treatment preferences
• Even Catholic hospitals and nursing homes now offer some kind
1) Be familiar with policies, statutes
of "living will" and most people falsely assume that such 2) Appropriate setting for the discussion
directives are automatically compatible with Church teaching. 3) Ask the patient, family what they understand
• While it has always been true that futile or excessively 4) Discuss general goals of care
burdensome treatment or care can morally be refused, the 5) Establish context for the discussion
Catholic Church has long condemned causing or hastening 6) Discuss specific treatment preferences
death, whether by omission or commission. 7) Respond to emotions
8) Establish and implement the plan

o Aspects of Informed Consent
Ø Problem treatment would address
Ø What is involves in the treatment/procedure
Ø What is likely to happen if the patient decides not to have
the treatment
Ø Treatment benefits
Ø Treatment burdens

Living Will
• However, no "living will" is risk-free and even refusing to sign a
"living will" is no guarantee that the "right to die" will not be
exercised for the patient despite his/her wishes.
• The best defense now is to have a loving relative or friend who
is informed about ethical options and who can legally speak for
the patient if he/she cannot because of illness or injury.
• It is also crucial that the patient chooses a doctor without a
"right to die" bias, preferably one with a good understanding of
Catholic ethical principles and Natural Moral Law.

Medical Power of Attorney
• A legal form that states who the patient wants to make
decisions about medical care
• The person is authorized to speak for the patient ONLY if the
patient is unable to make his/her own medical decisions
• May also be called:
Ø “health care proxy or agent”
Ø “health care surrogate”
Ø “durable power of attorney for health care”

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