The end of life decisions refer to the choices that bind a person in his/her terminal period of life. These are meant to fulfill the wishes of an individual concerning his health and any other relevant aspect of his/her life at this stage without the interference of the existing laws and or other people’s rights. In the following review, focus is made on the existing laws on ethical practice in medicine, the end of life decisions affected by the laws, and the relevance of each with regard to end of life choices. In the literature reviewed, euthanasia and living wills among other end of life choices have been looked at with a summary of the findings given herein. From the review, the American law aims at protecting the basic rights of every citizen entrenched in the constitution. Any other law that is reviewed is not supreme to this law. Various manuals and guidelines on ethical practice have also been reviewed with the conclusion that physicians should aim at prolonging life in every decision they make especially in terminally ill patients. The law also allows the application of the patients’ will in their management, and one may choose to have a do-not-resuscitate order or do-not-resuscitate-out-of-hospital order.
The population of the elderly people in the world is predicted to be on the increase with the number of chronic conditions also on the rise. This poses a challenge in the application of medical ethics that has been in existence since the times of Hippocrates and his popular oath that medical practitioners take. For about two thousand years now, the hypocritical oath has guided the medical practice and western physicians. Most other regions of the world use it as a baseline for medical ethics. The United States being party to most conventions on human rights has made laws seeking to harmonize the basis of medical practice to ensure that the actions of physicians and other medical practitioners are within the acceptable standards. These are entrenched in the constitution where basic rights of patients are protected alongside those of all other citizens, as well as other legal documents by binding medical authorities and bodies controlling health. Among the most controversial topics on medical ethics, the end of life choices contributes significantly. It is a subject of debate in most medical institutions and bodies. Differing opinions exist at the beginning and end of life with different parties using different views to support their opinions. There is a need to streamline medical services related to life decisions in the end of life due to differing opinions. It is therefore important to know the position of the American law on this crucial topic. Consequently, this paper looks at the existing literature concerning end of life choices and the laws existing on end of life decisions. The paper further shows how the two are related in the United States of America. The results of the literature review follow with appropriate recommendations and conclusions given accordingly.
As stated above, various literature materials state different views and opinions on matters of health especially on end of life decisions. Since the mid twentieth century, patients have taken an active role in their medical management. This ever-increasing consciousness has led medical institutions and medical practitioners to take the responsibility of informing and adequately educating patients in their course of management. Throughout history, medical practitioners have invested too much on the prevention of and dealing with death as opposed to dealing with patients in their terminal stages. This has led to decreased ability to deal with dying patients, their family, and the community hosting them. Until recently, medical courses have focused less on end of life decisions and care.
In their research, Billings and Block found out that only about 11% of the medical school deans they surveyed reported offering a course on dying and death in their respective institutions (1991, p.343). 52% were reported to offer the course somewhere within their curriculum with another 30% offering it as part of the course through a lecture or two in some of the courses. In the report, only five out of the 126 schools teaching medicine in the US had a complete and detailed course on death and dying that was independent on other courses. In her book, Allen states that ‘Death and Dying’ is an important topic in the training of medical practitioners, and emphasis should be made to improve on the care of terminally ill patients (2013, p.198). There is a marked improvement on the end of life care since the inception of the EPEC project (Education for Physicians on End-of-Life Care) that was formulated by the American Medical Association (AMA) in the year 1998. Patients who are seriously ill, those expecting death, those with chronic illnesses including cardiac diseases and cancer, and those willing to die to end their medical suffering deserve vigorous treatment of their condition with life prolonging drugs and those making their lives comfortable (Byock, 1997, p.48).
Several laws and guidelines relating to the end of life decisions exist with the American Medical Association contributing significantly to this. Some of them are contained in the guidelines published by the ethical and judicial affairs council. In addition, these spell the rules of engagement of physicians and patients (American Medical Association, 1992, pp.2229-2233). The guidelines spell the principle of autonomy where a patient has the right to make a decision to stop or prevent initiation of life prolonging treatment. They also emphasize on the palliation and prevention of pain to the patient even if such act reduces the survival of the patient and or if it prohibits physicians from carrying out mercy killings otherwise known as euthanasia besides prohibiting assisted suicide (American Medical Association, 1992, p.2230). The American College of Physicians has provided various guidelines on the end of life decisions and care in its ethics manual (American College of Physicians, 2005, p.15).
This spells out ethical measures similar to those by AMA including the clause that a patient has the right to make informed decisions concerning his/her management in terminal illnesses (American College of Physicians, 2005, p. 34). In the United States, the right to life is protected in the constitution, and is among the basic rights enjoyed by the citizens. The right to life act declares human beings as constituting of all the stages of life until their death. This is deeply vested in the constitution. In her book, Joanne Lynn (2004, p.73) stated that the end of life decisions such as euthanasia should be considered in making regulations and laws relating to the end of life decisions for terminally ill patients. She states that a living will is important in life and end of life decision making for the elderly. Meisel, another author, suggests in his book that patients nearing death should receive the same quality of care as those who have other illnesses (2008, p.24). The human rights act of 1998 has provisions, which enable the provision of medical services to the patients at the same basic baseline.
From the literature reviewed, emphasis is made on the need for harmonized law on the end of life decisions made therein. In most of the literature, the basic right of life is emphasized with each patient supposed to have this right provided and maintained even in terminal illnesses. The American law allows room for treatment of patients nearing death with the aim of prolonging life with no motivation of bringing death to the patient. The law also gives patients the freedom of making decisions regarding their medical treatment irrespective of their medical conditions, ability to communicate effectively, or their behavior. In the creation of living wills, a patient has to be above 18 years with at least two witnesses, both above the age of 18. This guarantees the right to make decisions regarding treatment measures to prolong the patients’ life or to withhold treatment. An outside the hospital do-not-resuscitate order allows patients nearing death wishing to die anywhere else apart from hospital to do so (Allen, 2013, p. 198).
In this agreement, a patient who knows that he/she is close to death may choose to go home from hospital and die in the comfort of his/her home. In the end of life decisions, the patients decide who inherits their property and estates. A will is therefore significant in the determining of whom to inherit property by a deceased, and this is prepared with legal advice. This has allowed disputes likely to develop after death to be reduced with the people obliged to follow the law. Life insurance proceedings are usually paid to the immediate beneficiaries of the deceased after his/her death as determined by the law. The same applies to bonds and safe deposit boxes owned by the deceased. From the literature, the actions that may accelerate death in patients with terminal illnesses include withdrawal of treatment meant to prolong life, euthanasia, provisions of treatment that may accelerate death but meant to palliate, and assisted suicide. Mechanical ventilation, per-enteral nutrition, intravenous antibiotics, and chemotherapy are some of the examples of drugs and procedures meant to prolong life in patients with terminal illnesses. Euthanasia causes death to a patient who is hopelessly ill to end his/her miseries. This often referred to as mercy killing. In the provision of the opportunity for the above end of life choices, one has to consider patient’s autonomy i.e. whether treatment offered is standard in practice and the policies in place allowing the carrying out of euthanasia.
From the above review, it is clear that end of life decisions form a large proportion of medical ethics in the practice of medicine. In practice, the law binds medical practitioners in their practice and respect for human life. The decision they make is therefore crucial. The American constitution protects individual’s rights with the most basic being the right to life. The law allows the exercise of patient’s opinion and decision in his/her management. If one makes a decision to end his/her life, the law has to respect the decision by allowing that. It is therefore recommended that patients are educated on their ability to choose their management concerning terminal illnesses and death. In most of the reviewed literature, recommendation by the bodies on medical ethic is that physicians should respect the decisions of patients with the capacity to make decisions. They also oblige physicians to provide pain-relieving medication besides promoting autonomy and dignity in terminally ill patients’ management. Provision of palliative care is also emphasized. Patients should receive it even if it shortens their life, as it improves their quality of life. It is recommended that more research into the effects of palliative care in reducing euthanasia requests be carried out. There is little research done to investigate the outcome of the number of patients requesting euthanasia, and this is required to provide a basis for any legislation to be enacted or any decision by medical legal bodies. Little research on the effects of end of life choices and the implications that they have on society have been done. There is therefore the need to carry out public awareness on the laws concerning the end of life choices and the implications on them.
In conclusion, the American law protects individuals unable to make decisions on their end of life. Besides, it is clear on the consequences. Where any medical practice concerning end of life decisions is involved, there exists guidelines and documents spelling out the proper laws that should be followed to maintain standard practice. There are also bills and amendments on the freedoms of individuals to ensure that there is no interference of human rights entrenched in the constitution in the process of making end of life choices.
Allen, J. (2013). Health Law & Medical Ethics for Healthcare Professionals. Boston, MA: Pearson
American College of Physicians. (2005). Ethics Manual. Boston: ACP Press.
American Medical Association. (1992). Decisions near the End of Life. Journal of the American Medical Association, 267(16), 2229-2233.
Billings, J., & Block, S. (1997). Palliative Care in Undergraduate Medical Education. Journal of the American Medical Association, 278(9), p. 343.
Byock, I. (1997). Dying Well: The Prospect for Growth at the End of Life. New York: G. P. Putnam’s Sons.
Lynn, J. (2004). Sick to Death and Not Going to Take It Anymore! Reforming Health Care for the Last Years of Life. United States: University of California Press.
Meisel, A. (2008). End-of-Life Care, in From Birth to Death and Bench to Clinic: The Hastings Center Bioethics Briefing Book for Journalists, Policymakers, and Campaigns. Garrison, NY: The Hastings Center, 2008.