Ethical Issues of Death & Dying
Although ethics is concerned with the difference between right and wrong, what is right and what is wrong when it comes to issues of death and dying vary widely from culture to culture, religion to religion, and even individual to individual. There are three general sets of ethical issues that need to be faced when considering matters of death and dying: Defining life and the cessation thereof; determining the quality of life that the individual experiences, and; deciding how the body should be treated after death. For many people, the parameters of ethical behavior are defined by their religious beliefs. No matter how decisions of death are dying are informed, however, such questions are best faced when the individual is still mentally sound and able to communicate his/her wishes. This ensures that the wishes of the individual are fulfilled upon death and makes it easier for the family to make decisions and prepare for the loss of their loved one.
Keywords Advance Directive; Culture; Dementia; Do Not Resuscitate Order; Ethics; Euthanasia; Extraordinary Measures; Heroic Measures; Living Will; Medical Device; Palliative Care; Quality of Life; Religion
Ethical Issues of Death
The approach of death is a difficult time as people struggle to resolve interpersonal issues before it is too late, put financial affairs in order, and make decisions about medical care. The person who is dying may also be attempting to come to terms with his/her death and the loved ones left behind may begin to realize that they are faced with the loss of their dying family member, friend or partner. In some cases, this realization is met with denial, and the family attempts to do everything in its power to prolong the life of the individual so that they do not have to face the loss. In other cases, either the terminal person or loved one may be overcome by despair, particularly if the patient is facing a lingering, painful death with no hope of relief. In still other cases, the family may be faced with the fact that their loved one is no longer able to communicate either because of dementia, coma, or other incapacitating illness, and will have a quality of life that is dismal at best. Despite the fact that neither the dying person nor their loved ones may be emotionally capable of making a rational decision at this time, important decisions still need to be made.
In general, there are three sets of ethical issues regarding death and dying that need to be considered when determining how best to meet one's end with dignity or support someone in doing so.
The first issue to be considered regarding the subject of death is the defining of criteria which constitute life. Before the invention of the mechanical ventilator in the 1950s, death could typically be determined by the cessation of breathing and the beating of the heart (although there were still exceptions to the rule). Today, however, scientific advances enable medical practitioners to prolong the regulation of such bodily functions by artificial means even when there is no hope of a meaningful recovery. So, the question remains: How are we to define death? Some theorists advocate for defining death in terms of the higher brain formulation of death which is defined as the "irreversible loss of that which is considered to be essentially significant to the nature of man" (Bernat, 2006). This approach rejects the concept that death should be defined in terms of an organism's inability to integrate bodily function. However, some people argue that this definition does not include the concept of an irreversible loss of consciousness and cognition (e.g., as in an irreversible vegetative state). Advocates of the whole brain concept of death maintain that death occurs only after “cessation of all brain clinical functions including those of the cerebral hemispheres, diencephalon, and brain stem” (Bernat, 2006). Although this debate may seem to be the picking of nits, it is an important question because families make their decisions about such issues as extraordinary measures, heroic measures, and life support based on whether or not they think the patient is still alive; sometimes regardless of whether there is any hope of a meaningful recovery.
Quality of Life
The second set of ethical issues regarding death and dying is quality of life that the individual experiences. The fear of death and the fear of dying are two different things. The first has to do with one's philosophy and theology; the second has to do with pain and suffering. As opposed to the people who believe that life (however it is defined) should be preserved at all costs, other people believe that a terminal diagnosis with a concomitant life of pain and suffering is not life at all and should be voluntarily terminated. In this set of ethical issues lie questions of death with dignity, removal of breathing machines, feeding tubes, and other medical devices that only prolong life but do not cure, assisted suicide, and euthanasia.
Body Treatment after Death
The third set of ethical issues is concerned with how the body is to be treated after death. Some people believe that a dead body is an empty shell requiring neither reverence nor respect. Others, however, believe that the body - dead or alive - is God's creation and deserves respect even after death. There are, of course, a range of opinions in between. One's stance on this issue can affect whether or not one wants to be buried or cremated, whether an autopsy should be performed, whether or not organs should be donated for transplant, or if the body may be donated to science. Culture, tradition, and religion all play prominently in this debate.
Quality vs. Quantity of Life
Although in some cases there may be technical, medical problems determining whether or not an individual is still alive, for the most part ethical questions concerning issues of death and dying center on the quality of the individual's life rather than the existence of it. On one end of the spectrum are people who believe that life should be preserved at all costs and that as long as a person can be kept alive (by natural or artificial means), there is still hope. On the other end of the spectrum are those who believe that the quality of life trumps all other considerations and that in terminal situations or those in which there is little hope for meaningful recovery and a reasonable quality of life, the life should be actively ended. In between, of course, is a whole range of other philosophies and beliefs.
A Personal Decision
Given the wide range of permutations on end of life issues and strong feelings along the whole continuum of belief, in the end, it can be argued that the ethics of death and dying are best left up to individual choice within the confines of the law. Issues of death and dying are about much more than medical treatment options and legal or medical definitions of death, and they do not affect only the dying person. Such decisions also involve issues of philosophy and theology. They can greatly affect not only the dignity, quality of life, and physical and psychological suffering of the dying person, but also the psychological well being of the living both during the dying process and after it. Therefore, decisions about death and dying are best made before they are needed and when the individual is still mentally sound and able to communicate his/her wishes. This will help to make sure that the person's wishes are carried out and that the family will not have to make extremely difficult decisions under extremely difficult conditions. In particular, drawing up a medical power of attorney, an advance directive, a do not resuscitate order, or a living will can help specify what the person wants and believes to be the right course of action when the time comes.
What makes the field of ethics so interesting is that although ethical questions deal with the process of trying to sort through issues of right and wrong, in many cases there are no right or wrong answers. For example, opinion is divided in the United States as to whether or not refusing to feed someone unable to feed him/herself and also unable to communicate his/her wishes is ethical. However, suicide by fasting to death is not only acceptable, but is a highly regarded and even celebrated aspiration within the Indian religion of Jainism. So, what is ethical in one culture may not be in another. There are many considerations in determining what is ethical or unethical in any given situation, and given the potential level of physical and psychological suffering in dying and the permanence of death, the stakes are high and opinions fiercely held. Religion informs the beliefs about death for many people, and may inform the decision making processes about issues related to death and dying culturally even for those who for most of their lives do not practice a religion. Although the theological principles pertaining to matters of life are death and not necessarily universally held within a given religion, the following discussion illustrates some of the more widely held principles and their theological underpinnings for five of the world's major religions.
The three major monotheistic religions of the world - Christianity, Islam, and Judaism - all have definite theology related to issues of death and dying. Christianity is the largest of these and, in fact, the largest religion in the world. Although Christians may be divided in many ways over issues of theology, they do hold the same core values and beliefs. One of these is that there is an afterlife in which believers will spend eternity with God. Although there may be dissention over smaller matters, in issues of life and death, there tends to be more common ground. Sickness, suffering, and death are viewed by many Christians through their understanding of Christ's suffering and death on the cross and his subsequent resurrection. Christians also believe that God participates in the affairs of humanity, another tenet that informs their views of death and dying. The New Testament teaches that one's body is the temple of God, so most Christians believe that life is sacred, although not necessarily to be preserved at all costs. For example, in questions of withholding or with drawing treatment, the official position of the Roman Catholic Church is that there is a distinction between ordinary measures (i.e., those medical treatments that are intended to preserve life such as medicines, treatments, and operations that offer reasonable hope for preserving life and that can be obtained without excessive expense, pain, or other inconvenience) and extraordinary measures (i.e., medicines, treatments, and operations that do not offer reasonable hope of preserving life and which cannot be obtained without excessive expense, pain, or other inconvenience). There is, of course, no list of procedures that easily fall into one category or another; all such treatment needs to be made with informed consent on an individual basis by the patient or family. For example, a feeding tube or mechanical ventilation at one stage during the course of a disease or illness may provide sufficient time for other measures to take affect and enable the patient...
(The entire section is 4999 words.)