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PubMed2004

Get out of jail free? The doctrine of double effect in English law.

The ethical doctrine of double effect permits health care professionals to administer potentially fatal medication, provided that their intentions are purely to control symptoms. In this article, the legal status and scope of the doctrine will be analysed, and it will be argued that the law in this context is unclear, incoherent and partial in its application. The problems are not exclusively legal in nature, however, because health professionals have been critical both of the doctrine itself and of the lawyers' understanding of the concept. It will be concluded that clarification and appropriate enforcement are needed if the doctrine and the law are to retain credibility.

Aged↗
PubMedDate not supplied

A moral dilemma: killing and letting die.

Most health care professionals believe that there is a clear difference between killing and letting die, i.e. between active and passive euthanasia. Philosophers, however, have repeatedly attacked the moral validity of their argument. This article explores various related issues and theoretical approaches to the distinction between acts and omissions.

Beneficence↗
PubMed2004

Responding to persistent requests for assistance in dying: a phenomenological inquiry.

Little is known about how American nurses understand and respond to requests made by decisionally capable patients for assistance in dying. This article is based on a broader qualitative study first reported elsewhere (Schwarz, 2003). The study used phenomenological interpretation and analysis of stories told by 10 nurses who worked in home hospice, critical care, and HIV/AIDS care settings. Persistent requests for assistance in dying were relatively uncommon, but when heard, participants provided the following responses: refusing assistance, administering palliative drugs that might secondarily hasten dying, tacitly permitting and not interfering with patient or family plans to hasten death, and actively providing direct assistance in dying. Nurses' responses were context-driven; they did not seek guidance from professional codes of ethics or colleagues. Secrecy and collusion were routinely practised. Few participants unequivocally agreed or refused to help patients die; most struggled to find morally and legally acceptable ways to help patients die well. Regardless of how they responded, nurses who believed they had hastened death described feelings of guilt and moral distress. Healthcare professionals who provide care for symptomatic dying patients need opportunities to meet with supportive colleagues, to share the experience of troubling cases and of moral conflict, and to be supported and heard in a 'safe' environment.

Adaptation, Psychological↗
PubMed1993

The morality of induced delivery of the anencephalic fetus prior to viability.

In situations where anencephaly is diagnosed and where the mother's life or health is threatened Roman Catholic hospitals are faced with the dilemma of waiting until viability before inducing the fetus, thus potentially putting the mother at further risk. According to most Roman Catholic ethicists, induced delivery before viability is contrary to the Church's prohibition of direct killing of the innocent. The authors propose for discussion a reconsideration of this position in the case of the anencephalic fetus and conclude that taking the life of such a fetus does not constitute an attack on its personal dignity and therefore is morally permissible.

Anencephaly↗
PubMed1995

Beyond Pittsburgh: protocols for controlled non-heart-beating cadaver organ recovery.

Much of the ethical debate about controlled non-heart-beating cadaver (NHBC) organ recovery has focused on the University of Pittsburgh Medical Center (UPMC) protocol. Some commentators have voiced serious reservations about the ethical acceptability of that protocol; others have argued that the protocol contains sufficiently stringent ethical safeguards to warrant a limited and carefully monitored trial at UPMC. UPMC is not the only organization pursuing controlled NHBC organ procurement, however. The study of organ procurement organizations described in this article suggests that controlled NHBC organ procurement is a practice that, if not yet widespread, is certainly no longer isolated to a few organizations in which it is carefully monitored. Rather, it is being carried out under a variety of circumstances, many of which are less carefully constrained ethically than at the University of Pittsburgh Medical Center. The next stage of the ethical debate should focus on issues that are arising in a variety of settings as the practice spreads.

Academic Medical Centers↗
PubMed1996

Pain relief, acceleration of death, and criminal law.

This paper considers whether a physician is criminally liable for administering a dose of painkillers that hastens a patient's death. The common wisdom is that a version of the doctrine of double effect legally protects the physician. That is, a physician is supposedly acting lawfully so long as the physician's primary purpose is to relieve suffering. This paper suggests that the criminal liability issue is more complex than that. Physician culpability can be based on recklessness, and recklessness hinges on whether a physician has taken an unjustifiable risk of hastening death. The authors identify three conditions of justifiability. Their analysis helps to explain the distinction between euthanasia, which is legally banned, and the use of risky analgesics, which is permitted in limited circumstances.

Analgesics↗
PubMed1998

The question not asked: the challenge of pleiotropic genetic tests.

Nearly all of the literature on the ethical, legal, or social issues surrounding genetic tests has proceeded on the assumption that any particular test for a gene mutation yields information about only one disease condition. Even though the phenomenon of pleiotropy, where a single gene has multiple, apparently unrelated phenotypic effects, is widely recognized in genetics, it has not had much significance for genetic testing until recently. In this article, I examine a moral dilemma created by one sort of pleiotropic testing, APOE genotyping, which can yield information about the risk of two different conditions -- coronary heart disease and Alzheimer's disease. A physician administering APOE testing for the beneficial purpose of assessing the risk of heart disease may discover medically useless and socially harmful information about the patient's risk of Alzheimer's disease. I explore how much providers should disclose to patients about pleiotropic test results and whether patients are obligated to know as much about their genetic condition as possible.

Dementia↗
PubMed2002

Conjoined twins and Catholic moral analysis: extraordinary means and casuistical consistency.

eThis article draws upon the Roman Catholic distinction between "ordinary" and "extraordinary" means of medical treatment to analyze the case of "Jodie" and "Mary," the Maltese conjoined twins whose surgical separation was ordered by the English courts over the objection of their Roman Catholic parents and Cormac Murphy-O'Connor, the Roman Catholic Cardinal Archbishop of Westminister. It attempts to shed light on the use of that distinction by surrogate decision makers with respect to incompetent patients. In addition, it critically analyzes various components of the distinction by comparing the reasoning used by Catholic moralists in this case with the reasoning used in other cases that raise similar issues, including women facing crisis pregnancies who prefer abortion to adoption and the Indiana "Baby Doe" case.

Abortion, Induced↗
PubMed2004

The dead donor rule: lessons from linguistics?

American society traditionally has assumed a univocal notion of "death," largely because we have only one word for it and, until recently, have not needed a more nuanced notion. The reality of death-processes does not preclude the reality of death events. Linguistically, "death" can be understood only as an event; there are other words for the process. Our death vocabulary should expand to reflect multiple events along the process from sickness to decomposition. Depending on context, some death-related events may constitute a more obvious discontinuity than others and more justifiably may be considered "death" within that context. There is no reason to assume a priori that there must be an overarching, unitary concept of death from which all diagnostic criteria must derive. Regarding organ transplantation, the relevant question is not "Is the patient dead?" but rather "Can organs X, Y, Z ... be removed without causing or hastening death or harming the patient?"

Animals↗
PubMed1994

The clinical management of dying patients receiving mechanical ventilation. A survey of physician practice.

OBJECTIVE: Despite mechanical ventilation's widespread use, there is scant literature to guide the management of patients receiving mechanical ventilatory assistance who are foregoing life-sustaining treatment. This survey was conducted to characterize physician treatment of such patients. DESIGN: Surveys were mailed to 513 randomly selected critical care physicians and returned by 308 (60 percent); 273 respondents were involved in ventilator management; all others were excluded. PARTICIPANTS: Forty percent of respondents were internists, 28 percent were surgeons, 16 percent were pediatricians, and 11 percent were anesthesiologists; 85 percent of physicians were board eligible/certified in a critical care subspecialty. RESULTS: Fifteen percent of respondents almost never withdrew ventilators from dying patients foregoing life-sustaining treatment; 37 percent did so less than half the time. Twenty-six percent of physicians believed there was a moral difference between withholding and withdrawing ventilators. Of physicians who withdrew ventilators, 33 percent preferred terminal weaning, 13 percent preferred extubation, and the remainder used both methods. Reasons for preferring extubation included the directness of the action (72 percent), family perceptions (34 percent), and patient comfort (34 percent). Reasons for preferring terminal weaning included patient comfort (65 percent), family perceptions (63 percent), and the belief that terminal weaning was less active (49 percent). Morphine and benzodiazepines were used frequently by 74 percent (morphine) and 53 percent (benzodiazepines) of physicians when withdrawing ventilators; 6 percent used paralytics at least occasionally. CONCLUSIONS: There is significant variation in the care of dying patients receiving mechanical ventilatory assistance, with 15 percent of respondents almost never withdrawing ventilators from such patients. Two very different methods of ventilator withdrawal each have advocates, yet rationales of patient comfort and family perceptions are matters of individual experience, absent published studies. The occasional use of paralytics during ventilator withdrawal raises concern about current practice.

Analysis of Variance↗