Euthanasia (Part 2)

By Jim McVeagh 24/12/2009


End of Life Issues

I have blogged about these issues before, using the sad case of Eluana Englaro as an example, here and here.

For most of us, death comes as a discrete event. The doctor pokes your corpse a bit, listens for a heartbeat and breathing, finds none and writes out your death certificate. You are then officially an ex-person.

For some, things are not so cut and dried. Large strokes, poor resuscitations and serious head injuries make up the vast majority of these poor people. People who are most probably dead, but bits of their body are still functioning. In Englaro’s case, Silvio Berlusconi, the Italian Prime Minister once famously and bizarrely observed that she could still bear children. I do hope they are not taking him too seriously at Copenhagen…

Regardless of the functionality of our reproductive organs or our kidneys or our liver, or even our hearts, the accepted neurological definition of death is the cessation of all higher brain function, even when stimulated. This can usually be determined by an EEG, but an MRI is more accurate. Usually this is sufficient when the patient is being ventilated. I think that ventilation is so obviously artificial, that relatives are far more accepting of the decision to switch it off. After all, they are not “switching off” their loved one, just a machine that is aerating a corpse.

The difficulty comes with a case like Englaro’s. Automaticity kicks in and the heart and lungs just keep going. If the unfortunate person is young, and feeding is maintained by nasogastric tube or stomach tube, then this half-life will persist, sometimes for decades. Even more complex are those who have some demonstrable, if inconsistent higher brain function, like Terry Schiavo, or have mostly normal brain function but are “locked in” – unable to initiate muscular action, including speech and eye movement.

In the second two cases, the discussion moves away from end-of-life to quality-of-life issues. These are not dead people, kept semi-alive by medical expertise. These are living, but severely disabled, people. There needs to be established brain death for this to be an end-of-life decision.

I am somewhat uncomfortable with the italian doctors decision to stop feeding Englaro. Although death by dehydration is not as uncomfortable as is sometimes made out, I have a problem with the assisted nature of this kind of death. It seems to me to be more ethical to continue feeding and nursing cares but to withdraw all medical interventions. After a month or two, she would have quietly succumbed to pneumonia or sepsis – a natural end for someone in a coma. Admittedly, it would be hard to question the ethics of even a lethal injection here, as Englaro had been technically dead for 17 years, but going against the Hippocratic oath so dramatically would not be a good thing.

While I think relatives have a perfect right to request that doctors do not intervene, the have no right to insist that we kill…

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