I hope that you can remember one of our case scenarios of recently concluded 'small group disscussions' and 'Medical Ethics Seminar', which dealt with the 'principle of double-effect'.
The scenario was as follows:-
A 72-year-old
man with a terminal cancer was discharged from the hospital as there was no
room. The consultant approached his relations and told them that if they could
afford he would get a better care in the X private hospital, in which he was a
major share holder. He was also prepared
to give them a substantial discount. Nevertheless, the relations declined the
‘offer’ as they couldn’t afford it.
At home the
patient was being looked after by his General Practitioner. He attended him
every week at home and prescribed pain killers as he was experiencing severe
pain. Since the oral pain killers became inadequate the doctor started morphine
injections.
One day the
patient confided in with the doctor that he wanted to commit suicide because
the pain is unbearable. He also asked the doctor to help him to achieve that,
which doctor flatly refused.
Meanwhile the
patient became resistant to the therapeutic doses of morphine. As a result the
doctor gradually increased the dose to as much as twice the recommended daily
dose.
The day in which
the morphine dosage was increased to that level the patient passed away peacefully
in his sleep.
Discuss the
ethical and legal issues.
Although a few ethical and legal issues can be identified in this case scenario I would highlight two ethical issues in this discussion. They are 'assisted suicide' and 'double-effect'.
Assisted-Suicide
Assisted-suicide is different from euthanasia. It is to help some one to commit suicide as the term implies. A doctor supplying a powerful sedative to a patient so that he can use them to commit suicide would be considered to have assisted him to commit suicide. Other than supplying the means of committing suicide (can be medications or any other means) the doctor (or any body else for that matter) does not have any active involvement in the death.
In terms of doctor's intention and active involvement in the death of the patient they both should be present in order to call it 'euthanasia'. In other words it is defined as killing a person with intention of relieving pain and suffering.
Assisted suicide is illegal in Sri Lanka though committing suicide or attempt to commit suicide is not illegal. It is illegal in many countries including UK, Australia, Germany. Nevertheless In Netherlands assisted-suicide and euthanasia (voluntary) are both legal since 2002.
This is a good example of the maxim 'some of the ethical and legal principles do not have universal application'. One day a student asked me whether not-aborting a genetically malformed infant is ethical. The answer I had insofar as the law and ethical principle are concerned was that they depend on the country where we discuss these matters. The perfect example is euthanasia and assisted suicide. Whereas there are illegal and unethical in Sri Lanka it is both legal and ethical in Netherlands. However, even in Netherlands they should be conducted under strict guidelines. Every case of euthanasia and assisted-suicide should be referred to a review committee. They will scrutinise them to see whether they have been done according to the guidelines. If not the doctor may be prosecuted in a court of law of unlawfully killing.
Principle of Double-effect
This was originally suggested by Thomas Aquinas, a Catholic philosopher and theologian lived in the 13 century Italy. He argued in his famous treatise ' Summa Theologica' that unintentional bad effects happened during an action of good intention can be justified. For instance killing a man in self defence can be pardoned as the good intention is to save one's life (which is the good effect) and killing of the man is the unintended bad-effect. Nevertheless if the way of killing is not proportionate to the act it can not be justified. This Roman Catholic doctrine is now applied to the 'end of life decisions'. This is permissible only if the action has at least one possible good effect in addition to the bad effects and four conditions or proviso's are met. They are
1. The action must not be immoral in itself.
2. The action must be undertaken with the intention of achieving only the good effect. Possible bad effects may be foreseen but must not be intended.
3. The action must not achieve the good effect by means of a bad effect.
4. The action must be undertaken for a proportionally grave reason (rule of proportionality).
According to this principle in order to make it permissible all the means of relieving pain and distress to the patient should have been exhausted, the patient should be in the 'end of life' situation, the intention should be to relieve pain although foreseen, the harmful side effects should not be intended, there should not be any safer or reliable alternative, the patient him/herself or surrogate should be consulted before commencing the treatment and the risk of such serious side effects should be proportional to the suffering. http://theoncologist.alphamedpress.org/content/5/1/53.full
Therefore, in this case scenario the doctor's action of giving twice the dose of morphine to relieve the pain can be justified even if he died as a result of overdose of morphine as he (doctor) seemed to have not intended to kill the patient.
Priyanjith Perera
15/12/2013
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