**3. Historical background**

The end-of-life has been a matter of reflection since the dawn of humanity. In the primitive settlements of mankind, the concerns were regarding the moment of death. As the process of civilization advanced to a high state of culture, in the Western world, since the time of Greco-Roman antiquity, the debate was mainly centered on the philosopher's concept of life.

The quality of life was valued much more than the extension of life at the cost of suffering; from this perspective, treatment stubbornness was not accepted,

The knowledge of the physicians was not based on science but rather on empirical experience of its practitioners, and, as such he was considered as a craftsman and not a specially designed technician. As a result, the quality of life had a primacy over the stretching of life with suffering.

In this regard, Plato's opinion is clear when he states that in terminal stages "*Bodies diseased inwardly and throughout should not be treated with gradual evacuations and infusions, to prolong a miserable existence*" [2].

Thus, the ethical concerns with death can be traced somewhere between the fourth and fifth century BC.

In the Medieval Europe, with the Christianization of the Roman empire, the sanctity turned to be the *leit motif* of life; the ethics of end of life were now focused on God, or to be more precise on the doctrine of Church.

In Renaissance and Illuminism, the new knowledge in Medicine led the great Master of Philosophy like Thomas Moore and Francis Bacon to introduce the discussion of euthanasia in cases where medical science had nothing more to offer. In Modern times, from the mid-twentieth century to the present day, the technological advances in sustaining the organ failures and pharmacological improvements and discovery of new drugs that can back up the biochemistry of the human body made exceptional advances in overcoming the organ failure.

On the other side, state-of-the art surgery techniques, and the control of tissue rejection through new immunological drugs turned the organ transplant into a reality: the scenario that was now perfect for the conquest of senescence, renewed the debates in ethical dilemmas such as dysthanasia (from Greek making death

difficult) wherein, the withholding and withdrawing life-sustaining treatments are the daily bread of intensive care units. Euthanasia, legalized in few countries is a subject of discussion, while ethical concerns about topics like drugs double effects and induced coma also deserve a reflection.

The discussion about the ethical dilemmas about end of life care in terminal diseases have been a subject of concern in all the civilizations, although written documents about the entanglement of the opinion makers, the philosophers and thinkers of the societies, are more easily traced in Western civilizations. Later, with the involvement of the church, the priests had a say regarding the end-of-life and finally with the evolution of medical knowledge the clinicians, had progressively a scientific ascendant regarding the dilemmas about treating terminal illness.

The delaying of the process of death with lengthening of the suffering is, nowa-days at the center of end-of-life ethical debates: the non-acceptance of suffering which can windup with the treatment limitation, at the request of the patient or as a decision of medical team, or as a request of euthanasia, also known as a merciful death, at the request of patient.

In the democratic societies, the decision itself has been subject of discussion. Who should be responsible for decision? The epistemic authority of those who have the knowledge. Or the moral authority of the patient, the family, the surrogate, or a judge in the name of state?

In a nearby future this is a debate that will continue to focus the attention of the modern societies.

### **4. Withdrawing and withholding life-sustaining treatments**

As described previously, in a medical procedure, the treatment is a consequence of diagnosis and should also take into consideration the expected prognosis. Moreover, the treatment strategy is not linear, that is, it can suffer abrupt changes mainly in intensive medicine where life sustaining treatments are involved: they may shift from maintenance of vital functions to palliative care.

As far as life sustaining treatments are concerned, there is a study in the USA, that revealed that in a five years interval of time, deaths in two intensive care units in a period of one year that resulted after withholding or withdrawing these treatments increased, in the same period, from 51 to 90% [3].

A French study involving 43 ICU's revealed that 52% of patients died after they had their treatment withdrawn or withheld [4].

Despite various meetings to standardize the criteria regarding the withdrawal or withholding of end-of-life treatments, cultural and religious barriers have made it difficult to have a uniform code of conduct. However, there is a consensus regarding the guidelines relevant to general principles of treatment renouncement, which can be summarized as: [5].


**33**

*End-of-Life Ethical Dilemmas*

procedure

reconsidered.

considerations.

treatment.

cause death.

*DOI: http://dx.doi.org/10.5772/intechopen.93616*

for the apprehension analyzed in minutia.

from the Mediterranean Europe side.

information is provided to the family.

goal of providing health services.

**5. Dysthanasia and euthanasia**

and the moment of death.

rather short interval of time.

a poison with the sole purpose to hasten or cause death.

• The withdrawal or withholding of life sustaining treatments is a medical

• In case of any deterrence to withhold life sustaining treatment, the withdrawal of the treatment already prescribed with the same objective should be

The decision of treatment renouncement deserves some reflections and

These decisions are seldom an urgent decision and, as such, it should not be a hasty and sudden verdict. As far as possible, it should be a consequence of a broad consensus. Any doubt, from any staff member, should be respected and the reason

Ethically, the withdrawal and withholding of treatment are identical attitudes, although, for some clinicians, it is more admissible to withhold than to withdraw

The treatment renouncement is considered, by some, as passive euthanasia. It is extremely important to realize that the intent of treatment renouncement is to withdraw or withhold an undesired treatment that can lead to the death of the patient, but not to induce the death of the patient. The distinction between dysthanasia and euthanasia is that in the latter there is an intention to administer a drug or

On ethical reasoning, in intentions and acts, there is a clear divergence between

The treatment renouncement decision has been a seat of disagreeing between

For the former countries (particularly the United States) the decisions, after the due explanations, rests entirely on the patient, while in European countries, particularly those in Southern Europe, the physicians are accountable for the decision. In ethical rationale, so far as the authorship of decision is concerned there is a confrontation between the two principles: autonomy from the Anglo-Saxon and beneficence

In my opinion, considering that the treatment renouncement is a medical procedure, the responsibility should be on the physician, after all the necessary

Is it morally acceptable, that the epistemic knowledge being on the physician side, the decision should rest on the patient or family part? Moreover, when any one

It is be retained and emphasized that treatment limitation is not synonymous with ceasing of any form of treatment. It is a shift from cure to care as the primary

In medicine, end-of-life care is made up of two constituents: the process of death

The process of death is a stage wherein an individual has been diagnosed with an infirmity, that by the existing biomarkers death will be a natural outcome in a

The physicians, with the technological equipment's and procedures at their

disposition, can lengthen or hasten the process of death.

of them (patient or family) are extremely fragile, weak and exhausted?

treatment renouncement and an attitude whose main and sole purpose is to

the Anglo- Saxon and Central and Southern European countries.


*Bioethics in Medicine and Society*

death, at the request of patient.

judge in the name of state?

modern societies.

be summarized as: [5].

condemnable.

withdrawal of treatment

and induced coma also deserve a reflection.

difficult) wherein, the withholding and withdrawing life-sustaining treatments are the daily bread of intensive care units. Euthanasia, legalized in few countries is a subject of discussion, while ethical concerns about topics like drugs double effects

The discussion about the ethical dilemmas about end of life care in terminal diseases have been a subject of concern in all the civilizations, although written documents about the entanglement of the opinion makers, the philosophers and thinkers of the societies, are more easily traced in Western civilizations. Later, with the involvement of the church, the priests had a say regarding the end-of-life and finally with the evolution of medical knowledge the clinicians, had progressively a scientific ascendant regarding the dilemmas about treating terminal illness.

The delaying of the process of death with lengthening of the suffering is, nowa-days at the center of end-of-life ethical debates: the non-acceptance of suffering which can windup with the treatment limitation, at the request of the patient or as a decision of medical team, or as a request of euthanasia, also known as a merciful

In the democratic societies, the decision itself has been subject of discussion. Who should be responsible for decision? The epistemic authority of those who have the knowledge. Or the moral authority of the patient, the family, the surrogate, or a

In a nearby future this is a debate that will continue to focus the attention of the

As described previously, in a medical procedure, the treatment is a consequence

As far as life sustaining treatments are concerned, there is a study in the USA, that revealed that in a five years interval of time, deaths in two intensive care units in a period of one year that resulted after withholding or withdrawing these treat-

A French study involving 43 ICU's revealed that 52% of patients died after they

Despite various meetings to standardize the criteria regarding the withdrawal or withholding of end-of-life treatments, cultural and religious barriers have made it difficult to have a uniform code of conduct. However, there is a consensus regarding the guidelines relevant to general principles of treatment renouncement, which can

• The treatment renouncement should result when the treatments have no longer

• The withholding of future treatment is morally and legally equivalent to the

any medical indication or do not offer any well-being to the patient

• A mindset, whose only aim is to hasten death, is morally and legally

**4. Withdrawing and withholding life-sustaining treatments**

may shift from maintenance of vital functions to palliative care.

ments increased, in the same period, from 51 to 90% [3].

had their treatment withdrawn or withheld [4].

• Any treatment can be withdrawn or withheld

of diagnosis and should also take into consideration the expected prognosis. Moreover, the treatment strategy is not linear, that is, it can suffer abrupt changes mainly in intensive medicine where life sustaining treatments are involved: they

**32**


The decision of treatment renouncement deserves some reflections and considerations.

These decisions are seldom an urgent decision and, as such, it should not be a hasty and sudden verdict. As far as possible, it should be a consequence of a broad consensus. Any doubt, from any staff member, should be respected and the reason for the apprehension analyzed in minutia.

Ethically, the withdrawal and withholding of treatment are identical attitudes, although, for some clinicians, it is more admissible to withhold than to withdraw treatment.

The treatment renouncement is considered, by some, as passive euthanasia. It is extremely important to realize that the intent of treatment renouncement is to withdraw or withhold an undesired treatment that can lead to the death of the patient, but not to induce the death of the patient. The distinction between dysthanasia and euthanasia is that in the latter there is an intention to administer a drug or a poison with the sole purpose to hasten or cause death.

On ethical reasoning, in intentions and acts, there is a clear divergence between treatment renouncement and an attitude whose main and sole purpose is to cause death.

The treatment renouncement decision has been a seat of disagreeing between the Anglo- Saxon and Central and Southern European countries.

For the former countries (particularly the United States) the decisions, after the due explanations, rests entirely on the patient, while in European countries, particularly those in Southern Europe, the physicians are accountable for the decision. In ethical rationale, so far as the authorship of decision is concerned there is a confrontation between the two principles: autonomy from the Anglo-Saxon and beneficence from the Mediterranean Europe side.

In my opinion, considering that the treatment renouncement is a medical procedure, the responsibility should be on the physician, after all the necessary information is provided to the family.

Is it morally acceptable, that the epistemic knowledge being on the physician side, the decision should rest on the patient or family part? Moreover, when any one of them (patient or family) are extremely fragile, weak and exhausted?

It is be retained and emphasized that treatment limitation is not synonymous with ceasing of any form of treatment. It is a shift from cure to care as the primary goal of providing health services.

### **5. Dysthanasia and euthanasia**

In medicine, end-of-life care is made up of two constituents: the process of death and the moment of death.

The process of death is a stage wherein an individual has been diagnosed with an infirmity, that by the existing biomarkers death will be a natural outcome in a rather short interval of time.

The physicians, with the technological equipment's and procedures at their disposition, can lengthen or hasten the process of death.

On the other hand, it is impossible to portray the moment of death. It is a moment of irreversibility that belongs to the sphere of the unknown.

#### **5.1 Dysthanasia**

In this context, the word dysthanasia that emanates from Greek – *dys,* in medical terms, painful and *Thanatos* meaning death – in common language means to retard as much as possible the process of death.

Although conceptually slightly different, treatment stubbornness, therapeutic doggedness, or medical futility have been used as synonymous. In dysthanasia, the attention is focused on the process of death, while in its synonymous, the point of convergence on persistency of cure-oriented treatment decisions, whose consequence may drag out the process of death.

In a context of a medical act, dysthanasia should be perceived as an approach where there is an excessive treatment in relation to the clinical condition and its expected outcome. From the perspective of a medical procedure and in the light of deontological precepts, treatment should consider the expected prognosis, as highlighted previously.

A basic rationale for dysthanasia can be a treatment that presents no beneficial odd for the patient.

For some time, dysthanasia was considered, in a broadest sense, futile care that does not benefits the patient. However, the term futile raised some polemic, since, futile, refers to anything that is unable or ineffective of bringing forth any useful result. Nonetheless, there are treatments that can cause some effect on patients' biological parameters without any beneficial good. This evidence highlights the argument that the effects and the benefits are different facts. The prolongation of life without any cognitive capacity and confined to an intensive care bed cannot, in my opinion, be considered the aim of Medicine. I am fully aware that this is a value judgment, and, as such, it is intrinsically difficult to reach a consensus.

The cause effect correlation, to be unequivocal, should be clearly defined and reproducible. The dispute around treatment stubbornness has been focused around difficulty in deciding what should be considered a medical futility and who should be responsible for this decision.

Regarding the definition, there is a distinction between quantitative and qualitative futility. The previous (quantitative) futility is based on statistical premises – a treatment is futile when the last 100 cases of a certain medical treatment for a distinct medical situation have been unsuccessful. On the other side, qualitative futility is related to a treatment that maintains a patient unconscious or does not withdraw his total dependency in relation to intensive care measures.

Summarizing, should the definition be mathematical or clinical?

Mathematics is a science of certainties while medicine (clinical) is a science of probabilities.

Can there be a minimum common denominator among this epistemic ambivalence?

Another worrisome dispute is related to the decision-making: who should have the ultimate say about the futility of a treatment: someone who has the scientific knowledge about the treatment and its effect (epistemic authority) or one, or his surrogate, who is the subject of treatment (moral authority)?

In this dispute I sign up the point of view of Theodore Brown. In his statement:

"*Moral authority is the capacity to convince others of how the world should be. This distinguishes it from expert or epistemic authority, which could be defined as the capacity to convince the others of how the world is*" [6].

**35**

*End-of-Life Ethical Dilemmas*

*in action but in knowledge"* [8].

help the patient in his illness.

from the same recrimination.

of a detrimental outcome [7].

and Age of Enlightenment, as mentioned earlier.

referred as "assisted death" or "friendly death".

unrelievable psychic or physical pain.

**5.2 Euthanasia**

In dysthanasia prevails the first one.

of all emotions and the denial of anguish [9].

*DOI: http://dx.doi.org/10.5772/intechopen.93616*

From all the consideration, previously exposed, it seems obvious that an act of dysthanasia or treatment stubbornness can be considered as an act of medical

In my opinion, a feasible and rational justification for dysthanasia can be met, on one side, at the light of philosophical underpinnings and, on the other side, as a

Philosophically, dysthanasia can be explained, among others, by the phenomenology of knowledge. Edgar Morin, the French sociologist, noted that "*The great contribution of knowledge left by the twentieth century was the knowledge of limits of knowledge. The major certainty is that uncertainties are unable to be eliminated not only* 

On the other side, the good or bad application of technique can be understood by the dialectic. Ethically, every man of science, in this case the physicians, serves two gods: the first god is that of ethics of knowledge – everything should be sacrificed to safe the thirstiness for knowledge. The second god is that of civic and human ethics.

Axiology, the philosophical study of value, can also be of relevance in explaining the treatment stubbornness. Since the Hippocratic oath, life is considered as a supreme value. By opposition, death has no value or is a non-value. If this rationale is righteous

Finally, a foundation for treatment stubbornness can be explained at the light of hope and escape. For Ernst Bloch, the German philosopher, hope is the most human

The physicians, particularly those dealing with severe cases, know from their experience, that there is, however small, a probability that the process of death may not be irreversible. Dysthanasia can find an underlying rationale in this hope or in

As pointed out previously, an argument for treatment stubbornness can rest in a reaction to an accusation of medical malpractice − defensive medicine. Currently, doctors are afraid of malpractice lawsuits; a physician response, entirely or to a certain extent, is based on medical procedures to evade any blame rather than to

Defensive medicine can be positive or negative. In the first setting unnecessary procedures are carried out by the doctors to safeguard himself against any complaint. In the second case, he abstains, from procedures and patients, to protect himself

In brief, in defensive medicine, the procedures result not from his innate values and beliefs, but from self-protection against accusation of misconduct in the advent

Perhaps, the most disputed end-of-life dilemma in the Western contemporary societies, is around euthanasia. However, its debate can be traced to the Renaissance

There are multifold descriptions of Euthanasia. In a medical understanding, it is an intentional act to end a life, to relief pain and suffering. The death is brought about by a doctor, family member or friend through a lethal injection and is at the request of the patient who suffers an incurable disease manifested through

The word comes Greek "eu" (goodly or well) and "Thanatos" (death). It has

malpractice. How can this demeanor by the physicians be explained?

safeguard against a complaint of substandard medical practice [7].

and undistorted, then treatment stubbornness can be justified.

other existential attitudes like escape or absurd rebellion.

#### *End-of-Life Ethical Dilemmas DOI: http://dx.doi.org/10.5772/intechopen.93616*

*Bioethics in Medicine and Society*

as much as possible the process of death.

quence may drag out the process of death.

**5.1 Dysthanasia**

highlighted previously.

be responsible for this decision.

odd for the patient.

On the other hand, it is impossible to portray the moment of death. It is a

In this context, the word dysthanasia that emanates from Greek – *dys,* in medical terms, painful and *Thanatos* meaning death – in common language means to retard

Although conceptually slightly different, treatment stubbornness, therapeutic doggedness, or medical futility have been used as synonymous. In dysthanasia, the attention is focused on the process of death, while in its synonymous, the point of convergence on persistency of cure-oriented treatment decisions, whose conse-

In a context of a medical act, dysthanasia should be perceived as an approach where there is an excessive treatment in relation to the clinical condition and its expected outcome. From the perspective of a medical procedure and in the light of deontological precepts, treatment should consider the expected prognosis, as

A basic rationale for dysthanasia can be a treatment that presents no beneficial

For some time, dysthanasia was considered, in a broadest sense, futile care that does not benefits the patient. However, the term futile raised some polemic, since, futile, refers to anything that is unable or ineffective of bringing forth any useful result. Nonetheless, there are treatments that can cause some effect on patients' biological parameters without any beneficial good. This evidence highlights the argument that the effects and the benefits are different facts. The prolongation of life without any cognitive capacity and confined to an intensive care bed cannot, in my opinion, be considered the aim of Medicine. I am fully aware that this is a value

The cause effect correlation, to be unequivocal, should be clearly defined and reproducible. The dispute around treatment stubbornness has been focused around difficulty in deciding what should be considered a medical futility and who should

Regarding the definition, there is a distinction between quantitative and qualitative futility. The previous (quantitative) futility is based on statistical premises – a treatment is futile when the last 100 cases of a certain medical treatment for a distinct medical situation have been unsuccessful. On the other side, qualitative futility is related to a treatment that maintains a patient unconscious or does not

Mathematics is a science of certainties while medicine (clinical) is a science of

Another worrisome dispute is related to the decision-making: who should have the ultimate say about the futility of a treatment: someone who has the scientific knowledge about the treatment and its effect (epistemic authority) or one, or his

In this dispute I sign up the point of view of Theodore Brown. In his statement: "*Moral authority is the capacity to convince others of how the world should be. This distinguishes it from expert or epistemic authority, which could be defined as the capacity* 

Can there be a minimum common denominator among this epistemic

judgment, and, as such, it is intrinsically difficult to reach a consensus.

withdraw his total dependency in relation to intensive care measures. Summarizing, should the definition be mathematical or clinical?

surrogate, who is the subject of treatment (moral authority)?

*to convince the others of how the world is*" [6].

moment of irreversibility that belongs to the sphere of the unknown.

**34**

probabilities.

ambivalence?

From all the consideration, previously exposed, it seems obvious that an act of dysthanasia or treatment stubbornness can be considered as an act of medical malpractice. How can this demeanor by the physicians be explained?

In my opinion, a feasible and rational justification for dysthanasia can be met, on one side, at the light of philosophical underpinnings and, on the other side, as a safeguard against a complaint of substandard medical practice [7].

Philosophically, dysthanasia can be explained, among others, by the phenomenology of knowledge. Edgar Morin, the French sociologist, noted that "*The great contribution of knowledge left by the twentieth century was the knowledge of limits of knowledge. The major certainty is that uncertainties are unable to be eliminated not only in action but in knowledge"* [8].

On the other side, the good or bad application of technique can be understood by the dialectic. Ethically, every man of science, in this case the physicians, serves two gods: the first god is that of ethics of knowledge – everything should be sacrificed to safe the thirstiness for knowledge. The second god is that of civic and human ethics. In dysthanasia prevails the first one.

Axiology, the philosophical study of value, can also be of relevance in explaining the treatment stubbornness. Since the Hippocratic oath, life is considered as a supreme value. By opposition, death has no value or is a non-value. If this rationale is righteous and undistorted, then treatment stubbornness can be justified.

Finally, a foundation for treatment stubbornness can be explained at the light of hope and escape. For Ernst Bloch, the German philosopher, hope is the most human of all emotions and the denial of anguish [9].

The physicians, particularly those dealing with severe cases, know from their experience, that there is, however small, a probability that the process of death may not be irreversible. Dysthanasia can find an underlying rationale in this hope or in other existential attitudes like escape or absurd rebellion.

As pointed out previously, an argument for treatment stubbornness can rest in a reaction to an accusation of medical malpractice − defensive medicine. Currently, doctors are afraid of malpractice lawsuits; a physician response, entirely or to a certain extent, is based on medical procedures to evade any blame rather than to help the patient in his illness.

Defensive medicine can be positive or negative. In the first setting unnecessary procedures are carried out by the doctors to safeguard himself against any complaint. In the second case, he abstains, from procedures and patients, to protect himself from the same recrimination.

In brief, in defensive medicine, the procedures result not from his innate values and beliefs, but from self-protection against accusation of misconduct in the advent of a detrimental outcome [7].

#### **5.2 Euthanasia**

Perhaps, the most disputed end-of-life dilemma in the Western contemporary societies, is around euthanasia. However, its debate can be traced to the Renaissance and Age of Enlightenment, as mentioned earlier.

There are multifold descriptions of Euthanasia. In a medical understanding, it is an intentional act to end a life, to relief pain and suffering. The death is brought about by a doctor, family member or friend through a lethal injection and is at the request of the patient who suffers an incurable disease manifested through unrelievable psychic or physical pain.

The word comes Greek "eu" (goodly or well) and "Thanatos" (death). It has referred as "assisted death" or "friendly death".

In this definition, in my opinion, the most inclusive, there are two premises – unrelievable pain and incurable disease − that need an added analysis and clarification.

Besides dissecting this definition, many a times the expression passive euthanasia is used to describe withholding of some medical procedures or treatments, which was already addressed in a previous section (Withdrawing and withholding life-sustaining treatments) that will need further consideration.

Unrelievable pain.

The state-of-the art in pharmacology has presented the medical science with drugs that can control entirely the pain. The main obstacle with the use of one or more pain killers lies with its side effects when there is a need to increase progressively the dose or upgrade the drugs. The most frightening side effect is the respiratory arrest.

In short, the drug outcome can result in a double effect. Reliving the pain but with a significant odd of causing death. Is it morally acceptable?

Besides the relief of pain, the terminal sedation has also been questioned.

This reflection and discussion will be done in next section.

Incurable diseases.

In Medicine, in a classic definition "incurable" implies an illness without cure that will lead, in a short span of time, to death. In natural history, some diseases, when untreated, end up with the failure of the organ and, ultimately, in the death of the patient. The organ failure can be a consequence of an acute condition or an endstage chronic situation. With modern technological achievements, many organs can be temporarily or permanently substituted by devices or transplants.

In my point of view, illnesses resulting from an end-stage chronic organ failure cannot be strictly defined as incurable in the sense that the outcome will be, unquestionably, the death of the patient, since the devices that substitute the failing organs can do their function.

The question in debate is whether there is any limitation to the use of these devices.

The permanent use of mechanical devices should consider the prognosis, the quality of life from the perspective of the patient and, first and foremost, the patient autonomy.

As previously stated, the treatment should be proportional to the expected prognosis.

It is accepted by some medical associations and by the Catholic Church, that "the use of extraordinary means to maintain life should be discontinued in an unrecoverable situation of a nearby, certainly fatal, prognosis and when the persistence of such treatments will not bring any benefit to the patient" [10].

Let us consider a situation of a patient with a chronic end stage disease but in full possession of his cognitive abilities who refuses any mechanical device to maintain his life. Should his will be denied because the withdrawal of the mechanical device will be considered by the physician or society an act of euthanasia? If, the alternative to a failing organ was its transplant, could the patient be forced to accept it?

Can a society or a physician impose their will? Is the informed consent a mere rhetoric?

By refusing the mechanical device the patient is rejecting to live permanently with a mechanical device. He is not asking to be killed, although he knows that the consequence of his wish will be his death.

In my opinion, the removal of a device that does nor suppress the evolution of the illness, instead prolongs the process of death cannot be considered an act of euthanasia.

**37**

*End-of-Life Ethical Dilemmas*

nasia, unless in bad faith.

**6. Drugs double effects**

drug is acceptable or not?

a slightly shortened life) [11].

good or as the end in itself.

to harm him (*primum non nocere*).

the harm.

*DOI: http://dx.doi.org/10.5772/intechopen.93616*

according to Kant is the only principle of morality.

range from mild to life-threatening conditions.

To recognize the restrain of science and technology is an act of matureness. To comply with the patient request is to respect the principle of autonomy, which,

It is my view, that many disputes and polemics in relation to end-of-life ethical dilemmas have its outset in the premise that the refusal of dysthanasia is an act of passive euthanasia. The objection of treatment stubbornness is act of good medical praxis and meets the *leges artis.* It cannot and should not be labeled as act of eutha-

All medicines used in a treatment may cause unwanted symptoms. They are also called "adverse effects" or "adverse reactions". Side effects happen when a treatment causes a problem because it does more than treat the target issue. Side effects can

In end stage diseases, when symptoms like pain or breathlessness are a source of great suffering of the patient, the physician is compelled to prescribe powerful analgesics or sedatives and these medicines may cause an undesired double effect. In case of an analgesic, besides alleviating the pain, they may depress the respiratory center and cause a respiratory arrest and ultimately the death of the patient. A major doubt, at the light of ethical principles, is whether the double effect of a

The principle or doctrine of double effect, often abbreviated as DDE, is a set of ethical criteria which Christian philosophers, like Thomas Aquinas' in his work *Summa Theologica*, have advocated for evaluating the permissibility of acting when one's otherwise legitimate act (for example, relieving a terminally ill patient's pain) may also cause an effect that he would, otherwise, be obliged to avoid (sedation and

In his assessment, this set of criteria is justifiable if the following are true:

The agent intends the good effect and does not intend the bad effect either to do

Resuming, the DDE is based on the idea that there is, morally, a pertinent difference between an "intended" outcome of an act and one that is foreseen by the actor

This doctrine has been criticized by the consequentialist, like John Stuart Mill, advocate of the utilitarian version of consequentialism. He argues that our moral analysis should ignore matters of motivation, which appeals to a distinction between intended and unintended consequences. In his opinion the scrutiny of motives will reveal a man's character, but utilitarianism does not judge character, only the rightness or wrongness of actions [12]. Thus, he concludes that the DDE should be rejected. Analyzing and reflecting the DDE at the light of ethical principles, namely of beneficence and nonmaleficence, it is clear that there is a clash between the duty to suppress harm or suffering (do good) and, perhaps, the oldest of codes of conduct that reminds the physician that his main attitude towards the patient should be not

In my opinion, even in common jurisprudence there a clear distinction between

intention and motive. The intention is the basic element for making a person

The good effect outweighs the bad effect, in circumstances sufficiently grave to justify causing the bad effect, and the agent exercises due diligence to minimize

The nature of the act is itself good, or at least morally neutral.

but not deliberately planned to achieve his motive.

#### *End-of-Life Ethical Dilemmas DOI: http://dx.doi.org/10.5772/intechopen.93616*

*Bioethics in Medicine and Society*

Unrelievable pain.

Incurable diseases.

can do their function.

patient autonomy.

devices.

prognosis.

rhetoric?

euthanasia.

clarification.

tory arrest.

In this definition, in my opinion, the most inclusive, there are two premises –

Besides dissecting this definition, many a times the expression passive euthanasia is used to describe withholding of some medical procedures or treatments, which was already addressed in a previous section (Withdrawing and withholding

The state-of-the art in pharmacology has presented the medical science with drugs that can control entirely the pain. The main obstacle with the use of one or more pain killers lies with its side effects when there is a need to increase progressively the dose or upgrade the drugs. The most frightening side effect is the respira-

In short, the drug outcome can result in a double effect. Reliving the pain but

In Medicine, in a classic definition "incurable" implies an illness without cure that will lead, in a short span of time, to death. In natural history, some diseases, when untreated, end up with the failure of the organ and, ultimately, in the death of the patient. The organ failure can be a consequence of an acute condition or an endstage chronic situation. With modern technological achievements, many organs can

In my point of view, illnesses resulting from an end-stage chronic organ failure cannot be strictly defined as incurable in the sense that the outcome will be, unquestionably, the death of the patient, since the devices that substitute the failing organs

The question in debate is whether there is any limitation to the use of these

The permanent use of mechanical devices should consider the prognosis, the quality of life from the perspective of the patient and, first and foremost, the

As previously stated, the treatment should be proportional to the expected

It is accepted by some medical associations and by the Catholic Church, that "the use of extraordinary means to maintain life should be discontinued in an unrecoverable situation of a nearby, certainly fatal, prognosis and when the persistence of

Let us consider a situation of a patient with a chronic end stage disease but in full possession of his cognitive abilities who refuses any mechanical device to maintain his life. Should his will be denied because the withdrawal of the mechanical device will be considered by the physician or society an act of euthanasia? If, the alternative to a failing organ was its transplant, could the patient be forced to accept it? Can a society or a physician impose their will? Is the informed consent a mere

By refusing the mechanical device the patient is rejecting to live permanently with a mechanical device. He is not asking to be killed, although he knows that the

In my opinion, the removal of a device that does nor suppress the evolution of the illness, instead prolongs the process of death cannot be considered an act of

Besides the relief of pain, the terminal sedation has also been questioned.

unrelievable pain and incurable disease − that need an added analysis and

life-sustaining treatments) that will need further consideration.

with a significant odd of causing death. Is it morally acceptable?

This reflection and discussion will be done in next section.

be temporarily or permanently substituted by devices or transplants.

such treatments will not bring any benefit to the patient" [10].

consequence of his wish will be his death.

**36**

To recognize the restrain of science and technology is an act of matureness. To comply with the patient request is to respect the principle of autonomy, which, according to Kant is the only principle of morality.

It is my view, that many disputes and polemics in relation to end-of-life ethical dilemmas have its outset in the premise that the refusal of dysthanasia is an act of passive euthanasia. The objection of treatment stubbornness is act of good medical praxis and meets the *leges artis.* It cannot and should not be labeled as act of euthanasia, unless in bad faith.
