Ethical consideration in end-of-life medicine

Abstract

With the advances of technology over the past decades, physicians, especially those who practice in the intensive care unit setting, are increasingly faced with patients who are not going to recover, but who are not going to die due to the application of modern treatment modalities. Development of life-sustaining technology brought about the expansion of the definition of death in the 1970s to include brain death. Brain death is recognized as the loss of whole brain function, including the brainstem. Philosophical arguments based on the unique aspects of human existence would accept a definition of brain death if higher cortical functions are lost despite on-going brainstem function. Confusion over seemingly optional definitions of death, circulatory death or brain death, has led to the belief that the newer, brain death, definition could be further refined to encompass the permanent cessation of the critical functions of the organism as a whole. Those functions being 1. vital functions of breathing and neurologic control of circulation, 2. integrating functions of physiologic mechanisms that maintain homeostasis, and 3. consciousness, as necessary for a person to maintain hydration, nutrition and protection Consideration of euthanasia likely is the basis of physician concern over withdrawing treatment and allowing a patient to die naturally. Physician aid in dying has become a major interest in ethicist circles. Those, whose arguments support an increasing physician role in assisting with the dying process, seek to eliminate the distinction between allowing a patient to die and actually killing. The capability of modern medicine and technology to keep patients alive has pressed physicians into an era where the very goals of medicine must be reviewed and perhaps revised. Patients who clearly would have died in prior decades now can survive; some but not all of whom being fully restored to normal functional existence. Medical practice which has progressed so well in answering the question of "How can we keep patients alive?" must now better answer the question "How should we allow patients to die and properly care for them?" In doing this we must remember our ethical duty to offer and provide only that care which is of benefit, not harmful, allowing patient’s to retain their decision-making right, while remaining mindful of our societal responsibility.