“I Will neither give a
Deadly drug to anybody if asked
For it, now will I make a suggestion?
To this effect”.

The Hippocratic Oath.

Introduction: — During the past century, dramatic changes have occurred in the Physicians ability to prolong life. Earlier to that, little more than rudimentary supportive care could be offered to the critically ill patients. Doctors now choose from a vast array of interventions that, often greatly prolong life. Unfortunately, the quality of the additional life so skillfully sought can be miserable, painful and degrading to the patient. Paralleling this has been the soaring coast of health care, scarcity of treatment resources for the care of the hopelessly ill and strident cries about rights of individual patients.

Therefore, a vigorous medical and political debate has begun again on euthanasia; a practice prescribed 2500 years ago in the Hippocratic Oath.

Definition: the ward has its origins from a Greek word – “Eu” means ‘well’ and “Thanatos “means ‘death’. Persons suffering from incurable. Conditions/disease.

Types of Euthanasia

1. Passive: A physician may choose not to treat acute bronchopneumonia in a patient with
2. Semipossive: A physician may withhold medical treatment such as nutrition or fluids from a Person in coma.
3. Semi active: A physician may disconnect a Ventilator from a patient who is in a stable
Vegetable state.
4. Accidental (Double-effect): A physician may administer a narcotic to relieve bone pain in a patient with terminal metastatic cancer and the narcotic may incidentally depress respiration sufficiently to cause death directly.
5. Suicidal: A physician may provide barbiturates or opioids, which the person with metastatic lung cancer may intentionally use in an overdose to cause his own death.
6. Active: A physician may administer a large, surely fatal overdose of morphine or potassium cyanide in a patient with AIDS who has indespreed Kaposi’s sarcoma.

General ethical fundamental: Some basic Principles:

1. Preservation of life
2. The alleviation of suffering
3. First do no harm.
4. Respect for the autonomy of the individual patient.
5. Ensure that medical resources are allocated fairly.
6. Truth telling; honesty.

Most of the debate on mercy killing revolves critically around this cluster and medical practice often brings this principle into conflict. Then which amongst these would take precedence?

Methods of Ethical reasoning:

William Franken distinguishes two philosophical theories of moral obligation – Teleological and deontological ethical theories.

Teleological ethical theories: This holds that the ultimate standard, which an act is judged morally right or wrong, is the general happiness of all people concerned, or the greatest not balance of good over evil. (J.s.Mill, G.E. Moore)

The decision-making process starts with the perception of a problem and proceeds to a listing of all the conceivable alternatives, for which consequence are predicted and values of happiness assigned.

The limitation of this method are that the method fails if one is unable to predict the consequences accurately or if one is unable to estimate accurate happiness values.
In addition, there is much disparity between the individual happiness and the general social welfare. Whose happiness is being considered when a respirator is turned off?

2. Deontological ethical theories: This maintains that there are rules or principles of action that have moral validity independent of the consequences and that one must act in accordance with these rules/ principles. They assert that there are considerations other than goodness/ badness on which decisions are to be based, things such as keeping a promise, maintaining justice, adhering to a commandment of God/state, which are important regardless of the consequence of the action.

Levels or Care: It can be useful for the physician to designate the level of care for the hopelessly ill patient that is appropriate at a given stage of the disease process.
General levels of care can be described as follows.

1. Emergency resuscitation: CPR.
2. Intensive care and advanced life support.
3. General medical care- Antibiotics, surgery, cancer chemotherapy, artificial hydration & nutrition.
4. General nursing care and efforts to make the patients comfortable, including pain relief and
Hydration & nutrition as dictated by the patient’s thirst & hunger.

Guidelines for decisions about initiating and maintaining life support measures (LSM):

1. Obtain the correct facts: Physicians should review the most current literature on the outcome of different life support measures in specified conditions.
2. Avoid irreversible decisions under uncertainly: L.S.M. should be initiated and maintained until there is time to review the facts, Prognosis and other ethical considerations
3. Withdrawing treatment is ethically preferable to withholding. It may be psychologically more difficult to stop treatment of a patient but it is preferable from the patient’s perspective.
4. Resolve disagreements with the use of outside consultation: If there is conflict with in the
Family/the treating team, outside consultations with ethics committees should be obtained.
5. Inclusion of the entire family in decision making process to avoid later disagreement and
6. Consent is a process & not events: So regular discussion should be hold the family regarding Continuation of LSM.

Hospital Ethics Committees: These are Voluntary multidisciplinary groups, which are based on a procedural notion of ethics called “Ideal observe theory”, which holds that decisions are more likely to be ethically defensible if they are based on:

1. Careful consideration of all relevant facts.
2. Decision arising from disinterested persons who have no rested interest in outcome.
3. Revivers who are dispassionate and do not get overwhelmed by emotion at times if crisis.
4. Empathy – The ability to put oneself in another’s shoes.

Physician – Patient communication: The physician should hold frank discussions with the patient and family. He should help the terminally ill patient to understand and deal with the prognosis and alternatives for treatment without destroying all hope.

One important consideration is the matter of Informed consent.
There are 3 basic requisites for this.

1. The patient must have the capacity to reason and make judgements.
2. The decisions must be made voluntarily and without coercion.
3. The patients must have a clear understanding of the risks and benefits of the proposed treatment alternatives, or non-treatment. In addition to being thoroughly informed, he must also understand clearly his right to make choices about the type of care to be received.

Do not resuscitate order: (DNR)

Three rationales for DNR:

1. No medical benefit: A commonly accepted ethical principle is that physicians have no obligation to provide medical treatment that is of no demonstrable benefit.
2. Poor Quality of life after CPR: The quality of life that would result after the cardiac arrest and the subsequent CPR is unacceptable.
3. Poor quality of life before CPR: Although the patient may survive the CPR, His current quality of life is judged unacceptable.

Quality of life (O1): It is defined by three components:
1. Functional status 2. Perception and 3. Symptoms .

1. This includes the ability to perform activities of daily living and to engage in social relationships.
2. This involves the patient’s perception of his health status, life satisfaction and general sense of well-being.
3. This involves the symptoms the patient experiences as a reflection of disease severity and the effects of treatment.

Q1 is a Central concept in the decision to initiate or withdraw life-sustaining, treatment because of:

1. Its role in clinical decision-making.
2. Its importance as a variable in prognostication.
3. Its importance as an outcome measure in evaluation of treatment.

Living Will: This term was coined by Luis kutner in 1969 to describe a document in which a competent adult sets forth directions, regarding medical treatment in the event of his future incapacities.
They suffer from 4 major shortcomings.

1. They are applicable only to those who are “terminally ill”.
2. They limit the types of treatment that can be refused.
3. They make no provisions for the person to designate another person to make decisions on his behalf.
4. There is no penalty if health care providers do not honor these documents.

Health care proxy: Also called the attorney/ agent/ surrogate.
This allows the competent adult to choose another person and assigns to him the power of attorney, such that he could make treatment decisions for him, if he becomes incompetent to make them.

A few land mark cases:

1. Geetruide Postma : 1971, Netherlands. Killing of a debilitated lady by her physician daughter.
2. Karen Ann Quinlan: 1976, New Jersey: Court authorized her removal from a ventilator.
3. Baby Doe: 1982, Indiana, with holding of medical treatment from a handicapped infant.
4. ‘Debbie’: 1988, Active Euthanasia of a terminally ill young women by a resident.
5. Nancy Cruzan: 1990, Missouri. Court disallowed the discontinuation of tube feeding.

Euthanasia in Netherlands: Only country where active Euthanasia is openly practiced.

75% of Dutch citizens new endorse mercy killing by physicians. The Dutch National movement for decriminalization of Euthanasia began in 1971 following the Gertrude Postma case. In 1985 the final report if the commission on Euthanasia recommended a new exception to the criminal code covering homicide – mercy killing. Hollano has not legalized mercy killing however, the physicians will not be prosecuted, provided they can prove that have following certain circumscribed guidelines before carrying out active Euthanasia.

1. There must be explicit and repeated request by the patient, which leave no reason for any doubt concerning his desire to die.
2. The mental / physical suffering must be very severe with no prospect of relief.
3. Informed, free and consistent decisions by the patient.
4. The last of other treatment options, those available having and having been exhausted or refused by the patient.
5. Consultation by the doctor with another medical practitioner and with nurses, pastors or others.

The usual method of performing euthanasia is to induce sleep with a barbiturate followed by a lethal injection of curare. Estimated 5,000 – 10,000 patients receive euthanasia each year in the Netherlands.

Euthanasia in India: Mr. Gopal Mandlik a well-known social worker in Poona ended his own life in 1980 after waiting fruitless sly for 2 yrs., for the Govt. of India to an end the I.P.C. to make it possible for him to do so legally. This was one of the factors that led to the establishment of the society for the right to die with dignity in 1981. This was the 28th of its kind in the world.

There has recently been a great deal of debate on this issue. Much of this is due to a bill introduced by Prof. S.S.Varde in the Maharashtra legislature provide immunity to physicians who withdraw life sustaining treatment.

Social Darwinism, Nazism and (?) Euthanasia: From the end of 19th century the idea of mercy killing without consent was combination of the biological theories of evolution and ‘selection’ were used to explain the difference in mental, physical and social qualities of human beings . The social Darwin’s like Tille (1895) Ploctz (1895) Binding and Hochos (1920) emphasized the danger for the eugenic welfare of the human race, and they were convinced that this could be avoided only by supporting the healthy through the extermination of the worthless and the defective.

Hitler and other National socialist leaders of Germany used this viewpoint of r justifying the extermination of thousands of people. The Nazis carried out the principle of “life unworthy of life” through 5 identifiable steps:

1. Coercive sterilization
2. Children action
3. T4 action
4. Killing of impaired in mates in concentration camps.
5. Mass killing of Jews in extermination camps.

However, one should be clearly aware that the Nazis never engaged in Euthanasia or mercy killing. What they did was merciless killing – either genocidal or for ruthless experimental purpose.

The Case against Euthanasia:

1. As public policy, euthanasia is unacceptable because of the likelihood of involuntary euthanasia. There are 4 ways in which this could happen: A. Crypthanasia B. Encouraged euthanasia C. Surrogate euthanasia D. Discriminatory euthanasia.
2. Euthanasia violates the norms of medicine:
a) It diverts attention from the real issues in the care of the dying patients – improved pain control, better communication between doctors and patients, respect for the patient’s rights to choose life sustaining measured, and improved management of the dying process, again * care.
b) Euthanasia subverts the social role of the physician as healer. Physicians have scrupulously avoided participating in punishment/torture. Physicians should distance themselves from euthanasia to maintain public confidence and trust in medicine.
c) Euthanasia strikes at the heart of what it means to be a physician. Since the time of Hippocrates, the prohibition against euthanasia has been fundamental to the medical profession.
3. Burdening the relatives with the decision of whether euthanasia is to be carried out may load to scruples of conscience and guides, and natural grief may became distorted.

Case for Euthanasia

1. Relief of suffering: A person who has become a vegetable mass of protoplasm and who has no hope of recovery, should has be forced to live? Should he not be allowed to die peacefully without suffering from further physical or mental agony?
2. Individual rights: The well recognized right of patients to control their medical treatment should include the right to request and receive euthanasia. While the state has given him the right to life, can’t he be endowed with a right to die?
3. Economics: Prevention of unnecessary and possible financial ruin of the family. Drain on resources for treatment of other patients who are not hopelessly ill.
4. Organ transplantation.
5. I few do find that decriminalization of Euthanasia leads us down the slippery slope’ we could always recriminalize it.

What is your Opinion  .YES OR NO .

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