1. END-OF-LIFE BASIC CONCEPTS “THOU OWEST GOD A DEATH”

2. QUALITY OF LIFE A FORMULA [SHAW, 1986/1994] QL = NE X (H + S) NE --- NATURAL (PERSONAL) ENDOWMENT H --- CONTRIBUTIONS OF THE HOME S --- CONTRIBUTIONS OF SOCIETY

3. QUALITY OF LIFE ESSENTIAL FEATURES [SPITZER ET AL., 1981] ACTIVITY (WORK, PLAY, STUDY) --- INVOLVEMENT IN OCCUPATION TASKS OF DAILY LIVING --- ORDINARY LIFE ACTIVITIES HEALTH (FEELING OF WELL-BEING) --- PERCEPTION OF ONE’S OWN HEALTH SUPPORT FROM FAMILY AND FRIENDS PSYCHOLOGICAL, SPIRITUAL OUTLOOK ON LIFE

4. QUALITY OF LIFE WAYS OF TALKING THE SUBJECTIVE SATISFACTION EXPRESSED OR EXPERIENCED BY AN INDIVIDUAL IN HIS/HER PHYSICAL, MENTAL, AND SOCIAL SITUATION THE SUBJECTIVE EVALUATION BY AN ONLOOKER OF ANOTHER’S SUBJECTIVE EXPERIENCES OF PERSONAL LIFE THE ACHIEVEMENT OF CERTAIN ATTRIBUTES HIGHLY VALUED IN OUR SOCIETY, AS REFLECTED IN A SOCIAL AND CULTURAL BIAS ABOUT THOSE FACTORS WHICH CONTRIBUTE TO A LIFE WORTH LIVING A LEVEL OF CAPABILITY AND ACTIVITY WHICH CONTRIBUTES TO THE INDIVIDUAL’S ABILITY TO FLOURISH –FLOURISHING --- THE FULFILLMENT OF THE POTENTIAL AN INDIVIDUAL MAY POSSESS FOR MEANINGFUL EXISTENCE [BEYOND MERE SURVIVAL]

5. MEANS FOR EXTENDING LIFE ORDINARY (PROPORTIONATE) –ALL MEDICINES, TREATMENTS, AND OPERATIONS, WHICH OFFER A REASONABLE HOPE OF BENEFIT FOR THE PATIENT AND WHICH CAN BE OBTAINED AND USED WITHOUT EXCESSIVE EXPENSE, PAIN, AND OTHER INCONVENIENCES EXTRAORDINARY (DISPROPORTIONATE) –ALL MEDICINES TREATMENTS, AND OPERATIONS, WHICH CANNOT BE OBTAINED WITHOUT EXCESSIVE EXPENSE, PAIN, OR OTHER INCONVENIENCE, OR WHICH, IF USED, WOULD NOT OFFER A REASONABLE HOPE OF BENEFIT. “ONE CANNOT IMPOSE ON ANYONE THE OBLIGATION TO HAVE RECOURSE TO A TECHNIQUE WHICH IS ALREADY IN USE BUT WHICH CARRIES A RISK OR IS BURDENSOME. SUCH A REFUSAL IS NOT THE EQUIVALENT OF SUICIDE [OR HOMOCIDE]; ON THE CONTRARY IT SHOULD BE CONSIDERED AS AN ACCEPTANCE OF THE HUMAN CONDITION.”

6. BENEFITS THE POSITIVE RESULT FOR A FUNCTIONAL IMPROVEMENT IN THE QUALITY OF LIFE OR THE ACHIEVEMENT OF A PARTICULARLY DESIREABLE GOAL WHICH AN INDIVIDUAL WILL EXPERIENCE AS THE RESULT OF A HEALTHCARE INTERVENTION COMPLETE RECOVERY REMISSION OF DISEASE PROCESS IMPROVED QUALITY OF LIFE –COMFORT –RESTORATION OF CONSCIOUSNESS –IMPROVED PERFORMANCE ACTIVITY RETURN TO A PREVIOUS LEVEL OF FUNCTIONING MAINTENANCE OF A MINIMALLY DECENT QUALTIY OF LIFE FIGHTING A DISEASE EXPERIENCING A LESS DISTRESSING DYING COST/RESOURCE SAVINGS [CONTINUED BIOLOGICAL EXISTENCE]

7. BURDENS THE SUFFERING ONE MUST ENDURE AS THE RESULT OF AN INTERVENTION; IT MAY TAKE A PHYSICAL, PSYCHOLOGICAL, SPIRITUAL, OR MORAL FORM TOO PAINFUL TOO DAMAGING TO BODILY SELF AND FUNCTIONING TOO PSYCHOLOGICALLY REPUGNANT TO THE PATIENT TOO RESTRICTIVE OF PATIENT’S LIBERTY AND PREFERRED ACTIVITIES TOO SUPPRESSIVE OF PATIENT’S MENTAL LIFE TOO EXPENSIVE

8. WEIGHING BENEFITS AND BURDENS WHAT IS THE GOAL OF THE INTERVENTION? –WILL THE GOAL BE ACCOMPLISHED? –RELATION OF GOAL TO PATIENT’S LIFE-STYLE CHOICES THE BENEFITS OF THE INTERVENTION? –RELATION OF BENEFITS TO LIFE-STYLE CHOICES –ARE BENEFITS WORTH THE BURDENS? THE BURDENS OF THE INTERVENTION? –RELATION OF BURDENS TO LIFE-STYLE CHOICES –ARE BURDENS TOLERABLE? –DO BURDENS MINIMIZE BENEFITS? WHO MOST DIRECTLY BEARS THE BURDENS? WILL THE PATIENT HAVE TO BEAR THE BURDENS ALONE?

9. ACTIVE - PASSIVE EUTHANASIA OLD STYLE ACTIVE –DOING SOMETHING/TAKING THE INITIATIVE DIRECT CAUSE IN PRODUCING THE EFFECT OF DEATH –E.G. GIVING A LETHAL INJECTION PASSIVE –NOT DOING A SPECIFIC THING/ALLOWING SOMETHING TO HAPPEN INDIRECT CAUSE IN PRODUCING THE EFFECT OF DEATH –E.G. WITHHOLDING OR WITHDRAWING AN INTERVENTION –ALLOWING THE NATURAL COURSE OF EVENTS TO FOLLOW

10. ACTIVE - PASSIVE EUTHANASIA NEW STYLE ACTIVE –DOING “x” = DOING SOMETHING PASSIVE –DOING “NON-X” = DOING SOMETHING BOTH INVOLVE TAKING AN INITIATIVE AND PRODUCING THE SAME END –UTILIZE DIFFERENT MEANS BOTH INVOLVE A DOING --- MINIMALLY A MENTAL ACTION MORAL EQUIVALENTS BUT MAY HAVE DIFFERENT PSYCHOLOGICAL EFFECTS ACTIVE MAY BE MORE HUMANE THAN PASSIVE SINCE SUFFERING IS TERMINATED SOONER

11. PRINCIPLE OF DOUBLE EFFECT ACTIONS WITH TWO EFFECTS; ONE GOOD, ONE BAD ONE MAY NOT WILL EVIL DIRECTLY ONE MUST INTEND THE GOOD EFFECT BUT MAY PERMIT OR TOLERATE THE EVIL EFFECT –E.G. REMOVAL OF VENTILATOR TO PRODUCE COMFORT –E.G. THERAPEUTIC LEVELS OF PAIN MEDICATION GOOD EFFECT MUST NOT COME ABOUT AS A CAUSAL RESULT OF AN EVIL ACTION –E.G. KILLING THE PATIENT TO ACHIEVE PAIN RELIEF THERE MUST BE A PROPORTIONATE REASON FOR THE PROCEDURE

12. VOLUNTARY AND INVOLUNTARY INVOLUNTARY –ACTIVE --- CONSTANT MEDICAL PROHIBITION –PASSIVE --- ACCEPTED AS W/W IN “HOPELESS” CASES (BENEFICENCE) VOLUNTARY –ACTIVE --- EQUIVALENT OF SUICIDE: STRONG MORAL PROHIBITION NO CONSTITUTIONAL PROTECTION REFUSAL OF TREATMENT, NOT SUICIDE –PASSIVE --- ACCEPTED AS TREATMENT REFUSALS (AUTONOMY)

13. WHY ACTIVE EUTHANASIA NOW? ASSISTED SUICIDE AND ALTERNATIVES TO AVOID PAIN –PAIN MANAGEMENT –WITHHOLDING/WITHDRAWING TREATMENTS T0 AVOID A PROTRACTED DYING PROCESS –SUPPORT PATIENT IN TREATMENT REFUSALS –EXPLORE POSITIVE AVENUES OF PERSONAL GROWTH TO AVOID INSTITUTIONS WHERE PATIENT “WILL NOT BE ALLOWED TO DIE” –CREATE ENVIRONMENTS TOLERANT OF A VARIETY OF DEATH-STYLES –UTILIZE WIDE RANGE OF ACCEPTABLE MEDICAL PRACTICES –ASSESS BENEFITS REALISTICALLY –RESPECT PATIENT AUTONOMY TO AVOID EXCESSIVE EXPENSES –RESPECT TREATMENT REFUSALS –ASSESS BENEFITS REALISTICALLY –UTILIZE LOW TECHNOLOGY INTERVENTIONS TO AVOID HUMILIATION AND INDIGNITY IN DYING –EXPLORE WAYS OF PROMOTING DIGNITY –EXPLORE AVENUES OF HOPE IN A LIMITED CONTEXT

14. TERMINAL [PALLIATIVE] SEDATION A FORM OF OR ALTERNATIVE TO EUTHANASIA? RIGHT TO CONSENT TO OR REFUSE TREATMENTS [PSDA] GOAL OF MEDICINE: RELIEF OF PAIN AND SUFFERING CAUSED BY MALADIES TREATMENT TO PROVIDE BENEFITS OR REDUCE BURDENS –PAIN –SUFFERING ADEQUATE PAIN CONTROL –HASTEN DEATH –PROLONG LIFE

15. TERMINAL SEDATION AND DOUBLE EFFECT TWO EFFECTS --- ONE GOOD, ONE UNDESIRABLE CANNOT ACHIEVE GOOD BY IMPROPER MEANS INTEND THE GOOD EFFECT; CANNOT WILL EVIL DIRECTLY MUST BE PROPORTIONATE REASON –RELIeVE INTRACTABLE PAIN –PRODUCE UNCONSCIOUSNESS BEFORE TERMINAL WEANING –RELIEVE EXISTENTENTIAL SUFFERING INTENTION [DIVIDING INTENTIONS] –RELIEVE PAIN [AND SUFFERING]/NOT CAUSE DEATH –SEDATION = RELIEVE PAIN WITHHOLD/WITHDRAW NUTRITION AND HYDRATION = NONBENEFICIAL