**1. Introduction**

Since the dawn of the hominization, one of the main distinguishing features of the humankind, was its concern with death.

Medically, death is defined as the irreversible cessation of all vital functions especially as indicated by permanent stoppage of the heart, respiration, and brain activity.

The focus on end-of-life ethical dilemmas are not mainly centered on the moment of death but rather in the process of death, the interval of time that encompasses the lifetime from the diagnosis of a disease that will irreversibly end, in a relatively short period of time, in the death of the person.

To understand the ethical problems of end of life, the discussion about the topic of this chapter reviewed the precepts of a medical procedure and the bioethical principles that professionals should refer to in case of confusion or conflict.

Although, currently very much in vogue, the end-of-life ethical dilemmas can be traced back to ancient Greece and Rome. Physicians and medical procedures about the end-of-life were a theme of opinion and cogitation and subjected to a code of conduct.

In those ancient civilizations, the apprehension which was initially centered on the metaphysics of moment of death shifted progressively to the quality and consequence of how one lived his life, in other words, there ought to be a nexus between the precepts that guided an individual life and his death.

In the western world, throughout the ages, the ethics of end-of-life was connected to the ideas the societies had about the philosophy of life.

With the evolution of science and technology the epicenter of the debate shifted from philosophy to the consequences of the inventions of technoscience. The innovations of devices that can replace the organs in failure, thus prolonging (dysthanasia) or shortening (euthanasia) of death process and medical procedures like withdrawing and withholding life-sustaining treatments, as well as the mechanisms and consequences of new and potent drugs, became the center of the controversy.

The arguments have considered the role of various sectors of the societies, from scientific to philosophical, including the religious perspectives and the best ways to overcome or at least mitigate the suffering that result from the dialectics of technoscience – the living will or health advanced directives.

The concluding remark of this manuscript is a tentative to explain the reason for the existence of dilemmas.

## **2. Medical procedures and ethical principles**

A medical procedure is not, merely, an interaction between the physician and the patient. In this intercommunication, there is also a third party involved, who may or may not be physically involved. On the other side, the outcome of this talk is also dependent on many interrelated vectors, where each one has an important and specific role [1].

For a better perception of the involved elements and circumstances let us consider them individually:

The importance of the third party in this relation is depicted with some examples: The third element can be the family, a financing partner or even the public opinion. Any one of them can influence the medical procedure.

It is well acknowledged the influence of the family in the principle of autonomy when the patient has no cognitive capacity and has no living will.

Other examples are the restrictions that the insurances companies impose on financial limits of a medical procedures. So, the outcome of a medical act, on ethical grounds, is dependent on the limits of the insurance card. Naturally, in most countries with a national health service, at least partially, this is not a major problem.

The fallout of the interaction between the physician and the patient depends also on cognitive, emotional, and cultural capacities, the communication skill, and the medical knowledge of the physician.

Another important vector to be considered in the outcome of the interaction between the patient and the physician is the venue, since the quality and approach of the medical procedure is different if it takes place at home, in a hospital or by the roadside. It is accepted, without any hesitation, that devices required in life sustaining treatments are not disposable at home or in a roadside procedure. Even in a hospital, the equipment's in a university or a central hospital are different and consequently the expected ethical principles will have to take into consideration the venue where the procedure takes place.

Other relevant vector that ought to be taken in consideration is, if the medical procedure is an urgency, emergency or just a routine medical procedure.

In the context of time, if the medical procedure is an emergency, no one expects the physician to ask and wait for informed consent. In these situations, the principle of autonomy, which clearly is determinant is a normal medical procedure, is considered a presumed consent.

And finally, a medical procedure is not a single act but a summing of diagnosis, treatment, and prognosis.

**31**

*End-of-Life Ethical Dilemmas*

setting of dysthanasia.

any medical intervention, namely:

**3. Historical background**

stretching of life with suffering.

fourth and fifth century BC.

enough in the local language to express their symptoms.

centered on the philosopher's concept of life.

*and infusions, to prolong a miserable existence*" [2].

on God, or to be more precise on the doctrine of Church.

exceptional advances in overcoming the organ failure.

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

The diagnosis does not seem to significantly influence the topic in question. However, the treatment and the prognosis are of utmost importance.

In a medical procedure, the prognosis is a fundamental and decisive component in treatment verdict. The treatment is expected to be proportional to the expected prognosis. In intensive medicine, a good example is the shifting from cure to care when the prognosis is unfavorable. The maintenance of treatment procedures or treatment stubbornness, despite the irreversibility of clinical situation leads to a

There are various factors that can impair and influence the prognostication, and all of them should be taught about while considering a patient's ultimate prognosis. In general terms, there are other factors that should be taken in consideration in

The importance of the cultural background in some bioethical principles: the principle of autonomy is determinant in Anglo-Saxon countries, while in Latin countries of South Europe, the principle of Beneficence has a clear ascendency.

The communications skills are also, progressively, becoming more important in a globalized world, since in more developed countries, more and more migrants, living within their borders, speak different languages or, at least, are not fluent

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

The quality of life was valued much more than the extension of life at the cost of

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

suffering; from this perspective, treatment stubbornness was not accepted,

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* 

Thus, the ethical concerns with death can be traced somewhere between the

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

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

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

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

*Bioethics in Medicine and Society*

the existence of dilemmas.

consider them individually:

medical knowledge of the physician.

venue where the procedure takes place.

specific role [1].

In the western world, throughout the ages, the ethics of end-of-life was con-

from philosophy to the consequences of the inventions of technoscience. The innovations of devices that can replace the organs in failure, thus prolonging (dysthanasia) or shortening (euthanasia) of death process and medical procedures like withdrawing and withholding life-sustaining treatments, as well as the mechanisms and consequences of new and potent drugs, became the center of the controversy. The arguments have considered the role of various sectors of the societies, from scientific to philosophical, including the religious perspectives and the best ways to overcome or at least mitigate the suffering that result from the dialectics of

With the evolution of science and technology the epicenter of the debate shifted

The concluding remark of this manuscript is a tentative to explain the reason for

A medical procedure is not, merely, an interaction between the physician and the patient. In this intercommunication, there is also a third party involved, who may or may not be physically involved. On the other side, the outcome of this talk is also dependent on many interrelated vectors, where each one has an important and

For a better perception of the involved elements and circumstances let us

The importance of the third party in this relation is depicted with some examples: The third element can be the family, a financing partner or even the public opinion.

It is well acknowledged the influence of the family in the principle of autonomy

The fallout of the interaction between the physician and the patient depends also on cognitive, emotional, and cultural capacities, the communication skill, and the

Another important vector to be considered in the outcome of the interaction between the patient and the physician is the venue, since the quality and approach of the medical procedure is different if it takes place at home, in a hospital or by the roadside. It is accepted, without any hesitation, that devices required in life sustaining treatments are not disposable at home or in a roadside procedure. Even in a hospital, the equipment's in a university or a central hospital are different and consequently the expected ethical principles will have to take into consideration the

Other relevant vector that ought to be taken in consideration is, if the medical

In the context of time, if the medical procedure is an emergency, no one expects the physician to ask and wait for informed consent. In these situations, the principle of autonomy, which clearly is determinant is a normal medical procedure, is considered a

And finally, a medical procedure is not a single act but a summing of diagnosis,

procedure is an urgency, emergency or just a routine medical procedure.

Other examples are the restrictions that the insurances companies impose on financial limits of a medical procedures. So, the outcome of a medical act, on ethical grounds, is dependent on the limits of the insurance card. Naturally, in most countries

with a national health service, at least partially, this is not a major problem.

nected to the ideas the societies had about the philosophy of life.

technoscience – the living will or health advanced directives.

**2. Medical procedures and ethical principles**

Any one of them can influence the medical procedure.

when the patient has no cognitive capacity and has no living will.

**30**

presumed consent.

treatment, and prognosis.

The diagnosis does not seem to significantly influence the topic in question. However, the treatment and the prognosis are of utmost importance.

In a medical procedure, the prognosis is a fundamental and decisive component in treatment verdict. The treatment is expected to be proportional to the expected prognosis. In intensive medicine, a good example is the shifting from cure to care when the prognosis is unfavorable. The maintenance of treatment procedures or treatment stubbornness, despite the irreversibility of clinical situation leads to a setting of dysthanasia.

There are various factors that can impair and influence the prognostication, and all of them should be taught about while considering a patient's ultimate prognosis.

In general terms, there are other factors that should be taken in consideration in any medical intervention, namely:

The importance of the cultural background in some bioethical principles: the principle of autonomy is determinant in Anglo-Saxon countries, while in Latin countries of South Europe, the principle of Beneficence has a clear ascendency.

The communications skills are also, progressively, becoming more important in a globalized world, since in more developed countries, more and more migrants, living within their borders, speak different languages or, at least, are not fluent enough in the local language to express their symptoms.
