Bioethics and End of Life Questions

Image by NASA and STScI from the Hubble website

I’ve been feeling a little philosophical of late. OK, so I always feel a little philosophical. Recent events have caused me to be even more so.

Consequently, bored on a Thursday night and browsing the list of available, streaming Netflix programming, I cam across a National Geographic Explorer episode entitled “Moment of Death.”

This short documentary, 50 minutes in length, talks about the death process from several different angles, from the medical to the experiential. While less than an hour isn’t really enough time to go into any aspect of the end of life in great detail, some of the subjects touched upon were very interesting. Of particular note was the question: when does life truly end?

It used to be, according to the filmmakers and those interviewed, that the moment of death was defined as that instant where the heart stopped beating. Now, however, death is considered to be more truly defined by a lack of brain function: brain death, where no electrical activity is occurring upstairs. The mind is gone … wherever it goes.

Of particular note was the brief mention of Karen Ann Quinlan, a woman brought to prominence in the mid 70’s when her parents requested she be removed from life support after entering a permanent vegetative state. More recently, the same set of moral and ethical questions arose surrounding Terri Schiavo.

And all this got me to thinking about the bioethics involved in the decision to stop artificially supporting life and let death occur.

When is it OK? When is it not OK? Who is morally obligated to do what? And who makes the decisions when a person can no longer make those decisions him/herself?

In “Moment of Death,” the case of a young man who suffered a gunshot wound to the head was discussed. “Mr. A.” was kept alive solely by external forces; machines breathed for him, thus his heart continued to beat. Over time, all brain activity ceased. There was no possible way he could ever be resuscitated. Consequently, one doctor commented, “He looks like every other patient in the hospital. Except I’ll be cutting out his heart.” She was talking about Mr. A. being a “living cadaver”: someone ideally suited for organ donation as the body is still functioning after all brain activity has ceased.

But what about Schiavo, who seemed to respond to some external stimuli, sometimes? (Though, truly, most of her brain seemed to have liquefied.)

When is it OK to die? When is it OK to let someone die?

Personally, if my brain had ceased functioning to the point where all traces of my personality were gone, I would not wish to be kept alive artificially. If I’m gone, I’m gone, and I can’t imagine the soul crushing despair a loved one must feel seeing someone lying in a hospital bed, connected to tubes, meters and machines, knowing there is no possible way of that person ever recovering. I can’t imagine putting the people I care about through the agony of watching a dead man still breathing.

From the point of view of someone who doesn’t believe in a God or a persistent soul, I can’t think of any moral implications to letting someone die. Certainly, from that perspective, the entire being is summed up in the brain, where we all live. But, as someone who is currently questioning whether there might not be a divine spark in us after all, the situation becomes muddier. On one hand, if God exists and we are all part of His divine plan, certainly nothing could happen without His approval. And, even if one does not believe in divine intervention in daily life, releasing the soul to whatever afterlife awaits. On the other hand, the argument that “nothing happens without God’s approval” is the same argument used by those who, through religious conviction, refuse medical attention for a sick child who could easily be cured by antibiotics or a simple surgical procedure.

And, if one considers divinity or God at all, there are moral implications not only for the dying person, but for those who made the decision. Is “pulling the plug” a merciful release, or is it murder?

Also, where do we draw the line in defining death? As one bioethicist noted in the documentary, he defines death not as the lack of electrical impulses in the brain, but in the irrevocable “death” of that which makes us … us: memory, personality, etc.

Is this a somewhat scientific restatement of saying: death occurs when the soul is gone? Or is it a slippery slope that will eventually endanger any patient in a coma and kept alive through artificial means?

And there are a range of situations to consider here beyond the persistent vegetative state: whether to resuscitate a patient when bodily functions have ceased, as well as the right of a terminally ill person undergoing tremendous suffering to end his or her own life.

If you’ve read my blog recently, you know I lost a friend last month due to cancer. David was a “do not resuscitate” (DNR) patient. He had signed a form instructing under what circumstances medical assistance could be provided. I always thought it would be a simple statement, such as, “if my heart stops beating, don’t start it again,” but it was much more involved than that. There were levels of medical assistance one could accept or decline: tube feeding, for instance. David wished for any medical intervention that could keep him alive, but none that could prolong his life artificially. It seemed to me a really gray area, with lots of things to consider.

In David’s situation, I don’t think there is anything medical professionals could have done. He had brain lesions from the cancer. His internal organs, including his liver, had failed. But, for the sake of argument, let’s say artificial respirators or a feeding tube could have kept his bodily functions active. Would David’s decision to refuse such care be considered a form of suicide? Certainly, if one believes allowing Karen Ann Quinlan to die by removing artificial life support murder, then it must be. Though, personally, I don’t agree.

If death isn’t a precise moment, as the documentary indicates, but a process, where along that process is it OK to choose death?

I know a lot of people who have died of terminal illnesses. Or, more precisely, some who have died of terminal illnesses and some who have chosen to end their lives waiting for the inevitable. In Washington State, voters in 2008 approved a measure allowing a terminally ill person access to a lethal dose of a particular medication.

Many, including some in the medical profession, consider this unethical. From certain religious points of view, this is considered suicide and thus immoral and, potentially, unforgivable. I know one medical student with whom I’ve discussed this issue who boiled it down to simply: it is a doctor’s job to save lives, not to end them.

If death is defined now as a process, rather than one instantaneous point of no return, where in this process do we cross the line where choosing death is acceptable? When one has a year to live? Six months? A week?

While I do believe in the right of self-governance, I must acknowledge the slippery slope here. We are, all of us, going to die. Therefore, we are all of us in the process of moving toward death all the time. Can one use any of the above justifications to make a “right to die” argument for what one considers a “healthy” individual? If one disagrees with the “right to die” line of reasoning, then certainly not. But if one embraces it, then where along that gradient of grayness does one cross the line?

If ending physical suffering is considered ethical, how much longer before we – as a society – embrace ending emotional or mental suffering?

I guess the real problem as I see it is this: life is very personal, and so is death. Each individual’s needs are unique. Perhaps death really isn’t a moment, but a process. Perhaps there are shades of gray in each individual case. But we can’t apply a moral and ethical framework to our society, whether through legislation or forming cultural norms, that isn’t delineated.

 

 

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5 Responses to “Bioethics and End of Life Questions”
  1. Kara says:

    I think this the concept of “end of life” differs for everyone. My grandfather is in the fourth and final stage of dementia; before much longer he’s going to have difficulty swallowing. Eventually he will require a feeding tube. He also has leukemia and emphysema, diabetes, and a host of other things wrong with him. But it’s the dementia that trumps all at this point. While he was still in his own mind, he announced that he didn’t want anymore surgeries, and essentially wanted to file the DNR paperwork. For him, quality of life did not include being subjected to any more surgeries. At all. No more. His attitude was, “I’m 87 years old. I’ve had a long life. When it’s time, then it’s time.”

    This was a year ago.

    I tend to think, insofar as religion is concerned, you’ll get as many different viewpoints as you have personalities. Some believe that even if a body can be kept alive through artificial means, then that body should be kept “alive” for as long as medically possible. I… can’t help but feel this is inadvertently cruel in the long run. What is life, after all? If life is meant to be a gift from God that we aren’t meant to squander, then how can one argue that being kept alive by artificial means is in any way appreciating such a gift?

    Personally? I think (a) it should be between you and God and (b) make damn certain your wishes are known. For each person that DNR point is going to be different. I agree with you, though, I think — once *I* am gone, my personality, my mind, and whatever other qualities make me, ME… then essentially, keeping the body alive edges into cruelty. (And if you do believe in the concept of a soul, then what if those measures are trapping the soul in the body, preventing it from leaving? How is that living? How is that cherishing the gift of life?)

    Sadly, I think a great deal of the obsession with keeping people in a vegetative state “alive” stems largely from the selfishness of the living. We don’t like letting go, and even if the person’s mind and personality are gone, and nothing is really left but the shell, there’s still a strong attachment to the physical there.

    I have… so much more I could say on this, but I I think I’ll stop there for now. :)

    ~Kara

    • Kara,

      Thanks for the awesome comment! Definitely lots to consider. My own grandfather had Alzheimer’s and lung cancer. His dementia didn’t seem to bother him, so it didn’t bother me. When we finally had to have him hospitalized, the doctors said he could live up to two more years, but would need to be in a nursing home and under 24 hr care for the rest of his life. He died the same night.

      • Kara says:

        My grandfather has… fleeting moments of lucidity, and that’s the kind that hurts the most to see. During one such moment he told my mother (his primary caregiver) that he could feel himself losing his mind, and he was just so frustrated because he knew there was nothing he could do to stop it. “People joke about losing their mind,” he said. “And now I am, and I can’t stop it.”

        (Insert rage here about Medicare cuts and the wheelchair that got taken away from him because he didn’t die, and, oh, how I WISH I was exaggerating right there.)

        But watching this and being close to it (we live next door to my mother and grandfather) has also helped me in a strange way to really … pay attention to life, and the little moments, and it’s helped me be thankful even when things suck. One of the best days I had in a while was when I played a game of pool with him — we didn’t follow the rules, mainly because he couldn’t remember them, but it’s going to stick in my memory for a long, long time.

  2. DCG says:

    I am a Christian and had two loved ones dies of terminal illnesses. They were Christians as well and both had DNRs. They suffered at the end but were comfortable (inasmuch you could do). I don’t believe that artificially prolonging life is any life at all. Making those passing on most comfortable should be the goal until they reach their journey with God.

    I voted against that measure in 2008. While watching my loved ones dies was not pleasant, in those last days you could see they reached peace. My grandmother in particular was most alive (in her eys) in those last few days. I don’t believe in ending your own life as Jesus suffered for us. Those who suffer on earth learn humility and the presence of his grace. Maybe not the best way to word yet I’m not as articulate at the keyboard as you are :)

  3. brendayaziyor says:

    “Nothing happens without God’s approval.”

    That argument is a false argument that people make that does lots of damage to those who hear it or who are “ruled” by it (as that child would be by parents who hold that idea). Nothing happens without God’s KNOWLEDGE, but He doesn’t approve of many things that we do or that others do to us. God knew I would be born, knew about my parents’ divorce, knew where I’d attend university and where I’d be living now. I don’t believe God approved my parents’ divorce: they just quit getting along. Why would God want that? He allowed it; He knew about it; He didn’t approve it. Part of who I am–working with kids, friends I’ve made—is better because of my experiences. However, those who use “nothing happens without God’s approval” as an excuse for sin, neglect, destruction or similar harm are wrong, wrong, wrong. God wouldn’t want that sick child to die. He didn’t approve it. “Humans” (who weren’t being very humane) did.

    …death occurs when the soul is gone?

    Can we know when the “soul” is gone? Is the soul’s existence indicated by brain activity? I guess it was Descartes that said, “I think, therefore I am.” If you can no longer think, because there is no visible brain activity, is the soul “gone”? I admit I don’t know. As a Christian, I know that I am prepared for the moment that my earthly existence ends. I would like to live on Earth many more years, but when I do die, whatever that may look like, I will “absent from the body and present with the Lord.” Paul wrote that himself in 2 Corinthians 5. He also wrote in Philippians 1 that he was torn between the two: to live so that he could serve and encourage others in their Christian faith, or to die and be in heaven with Christ. So…

    Where along that process is it OK to choose death?

    As long as a soul is alive, they have the opportunity to follow Christ. I would be heartbroken if I was asked to remove a friend or family member from life-support if I was not certain that they had chosen to follow Christ while they yet lived.

    I don’t have a living will, though I am a registered “organ donor.” A family member shouldn’t be burdened with making that decision, though, and neither should a doctor. I believe that if I don’t specify what should happen to my body in such a situation, undue pressure will be put on those who are left behind. I guess that means I need to put some ideas down on paper.

    This one thing I do know and believe: God’s plan for me does not depend on IVs, ventilators or defibrillators. When I die, the moment that I die, I will be with God immediately and forever. He knows the moment that will happen, and He has made all the necessary preparations. “It is finished.”

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