Legal & Ethical Issues of Life & Death
As advances in medicine expand the possibilities of life, postpone death, and expand the knowledge of the genetic and molecular makeup of human beings, new issues emerge in the legal and ethical issues of life and death. The United States Supreme Court has legalized the right of every individual to prepare health care directives concerning the nature and extent of end-of-life treatment and care. Less accepted is the concept of physician-assisted suicide, in which the health care provider assists the individual in selecting the time and manner of his or her death. These issues are complicated further when the patient is poor or mentally or physically challenged. Additionally, there may be limits on financial and medical resources, further requiring individuals and their families to make hard decisions about life and death. This article will explore some of the contemporary legal and ethical issues of life and death in the United States.
Keywords Advance Care Directives; Americans with Disabilities Act; Antitrust Laws; Cannabis; Health Care Proxy; Living Will; Marijuana; Medical Power of Attorney; Palliative Care; Patient Self-Determination Act; Physician Assisted Suicide (PAS); Resuscitate; Schiavo, Terri
Sociology of Health
A large metropolitan hospital receives a call that an infant in critical condition is arriving for care. All of their extracorporeal membrane oxygenation (ECMO) machines, which give blood oxygen outside the body when a ventilator is not sufficient, are in use. What is the ethical thing to do? Place the new patient on an ECMO machine because they are critical? First come, first served? Or should the doctor consider which children have the better prognosis and treat them first?
Famed New York Yankees slugger Mickey Mantle was inducted into the Baseball Hall of Fame in his first year of eligibility in 1974. Mantle suffered from alcoholism, cirrhosis of the liver, and hepatitis C, and seems to have been inducted into the liver transplant program at Baylor University Medical Center in Dallas, Texas, with equal ease in 1995. Despite a terrible prognosis and a long line of patients also waiting for a liver transplant, Mantle received the transplant and lived only another two months. Public outcry over the power of celebrity and how transplant organs are allocated raged for months.
The legal and ethical considerations of life and death are numerous and without absolute answers. They can be complicated further if the patient is elderly, mentally or physically challenged, poor, and/or without sufficient health insurance. In an ideal world, none of these conditions would be the basis for making life and death decisions. But as society makes unimaginable medical advances, the price tag for these life-saving treatments continues to soar. Individuals, and state and federal governments, are staggering under the huge bill for health care insurance and treatment.
Sociologists, legal theorists, politicians, and the public are interested in these matters as evidence of social change and the tensions between personal freedom and public constraints upon those freedoms. Although the Declaration of Independence mentions "life, liberty, and the pursuit of happiness," for example, there is no mention of privacy rights or individual freedoms pertaining to biological and/or medical issues. Given our country's Puritan/Protestant religious background, rule by the majority has dominated many of these ethical and legal matters for centuries. Over the last forty years, however, emergent medical advances and beliefs in privacy and personal decision-making have changed the landscape of debate. All across the nation, scholars see evidence of the struggles between traditional values and emergent personal freedoms on local, state, and national levels. On the other hand, some of these issues, such as the allocation of transplant organs or setting limits on medical interventions, are caused by relatively recent medical breakthroughs that have no precedent in modern society. In some ways, it is difficult for society to debate these issues since the two means of resolution have been the courts and legislative action. How different groups conceptualize each of these issues, and how the larger society engages in the debate and temporary resolution of these matters is of major interest to sociologists interested in social change and ideological/social conflicts.
Advance Care Directives
In terms of end-of-life care, normative statements from the American Medical Association state that "the primary consideration should be what is best for the individual patient" (American Medical Association, 2007b). Physicians are not required to provide care that has no "reasonable chance of benefiting the patient" (American Medical Association, 2007c). If the medical interventions are viewed as futile, then the process changes into one of making the patient comfortable and pain free, both mentally and physically.
Advance care directives are formal, written, and signed documents that provide legal and medical instructions concerning an individual's wishes for their medical treatment, even when they are no longer able to actively participate in those decisions. Often called a "living will," "health care proxy," or "medical power of attorney," these types of documents empower a surrogate decision-maker or caregiver and delineate the treatments desired or refused during illness or at the end of life. Often included in these documents are "do not resuscitate (DNR)" instructions in the event that a patient suffers cardiac or respiratory arrest and their medical condition does not warrant cardiopulmonary resuscitation. Individuals with inoperable, terminal medical conditions or those facing a long-term coma with no hope of recovery are most likely candidates for DNR orders.
State and federal laws encourage these types of patient decision-making in order to avoid court-ordered determinations of the patient's wishes. In 1991, the US Congress passed the Patient Self-Determination Act (PSDA), which mandates that any health care institution receiving Medicaid or Medicare funds must inform patients of their right to self-determine their end-of-life care. Despite this law, and the ugly legal battles played out in media and political circles, estimates are that fewer than 29 percent of adult Americans have advance directives. The failure to make these important medical and legal decisions can place the patient, the family, and medical care providers in an expensive and complex legal battle over what should be done on the patient's behalf.
That was the situation in the famous Terri Schiavo case, in which both the state of Florida and the then-conservative United States Congress intervened to try and stop the removal of feeding tubes for Schiavo, who had been in a persistent vegetative state for fifteen years. In 1990, Schiavo suffered irreversible brain damage after experiencing both respiratory and cardiac arrest. In 1998, Schiavo's husband petitioned the court to remove the feeding tubes, arguing that Schiavo would not have wished to continue to be kept alive in such a condition. Schiavo's parents disagreed, and the ensuing legal battle took seven years and involved both the Florida and the United States Supreme Courts. Although both federal and state congresses attempted to pass laws prohibiting the removal of the feeding tubes (and some ardent Congress members sought to have Schiavo qualified for the federal witness protection program), ultimately the courts permitted the feeding tubes to be withdrawn. Two weeks later, Terri Schiavo died at the age of forty-one. Pro-life advocates called the court's decision "judicial murder," while disability advocates were on both sides of the debate.
Physician-Assisted Suicide (PAS)
Physician-assisted suicide (PAS) is "when a physician facilitates a patient's death by providing the necessary means and/or information that enable the patient to perform the life-ending act" (American Medical Association, 2007). Arguments in favor of PAS are that individual autonomy should be respected, as well as individual liberties, and that it is simple justice since the individual already has the right to refuse treatment. Why should they not have the right to choose when they die? Some consider PAS to be a compassionate solution to terrible pain and suffering. Finally, others argue that PAS already is occurring, particularly in the use of morphine drips that lessen pain but also negatively impact the respiratory processes. To make PAS legal would be to bring the discussion of end-of-life options out into the open for both the patient and the physician ("Physician Assisted," n.d.).
Opponents of PAS argue for the sanctity...
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