An Ethical Exploration

Write a report which examines an ethical and moral dilemma occurring in a health and social care environment or other similar work-based environments.

The term ethics has been defined as the “study of the moral value of human conduct and the rules and principles that ought to govern it” (McLaren, 2012, p. 69). Another definition of ethics is provided by Grenz and Smith (2003) as a division of philosophy involving “the study of how humans ought to live … if morality involves the actual practice of living out one’s beliefs, then ethics is the study of why these practices are moral or immoral” (Grenz and Smith, 2003, p.35). These definitions of ethics suggest that ethics relates to the moral value or moral content of our actions and decisions. Ethics or ethical principles allow us to ascertain whether our actions and decisions are right or wrong based on the moral content of these actions. Moral dilemma is involved where we are posed with two or more choices, none of which may be completely acceptable but where to not make a choice is also unacceptable (Grenz & Smith, 2003). In this essay, the moral dilemma related to assisted dying is discussed critically. This moral dilemma is relevant because of its impact on the health care and social care environment where medical professionals or carers may find themselves faced with this dilemma in the context of their practice. In this essay, ethical principles related to the moral and ethical dilemma of assisted dying is explored in the context of the health and social care environment. Assisted dying is also linked to key issues such as, autonomy of the individual, consent and the principles of medical ethics, such as, beneficence, best interests of the patient, and an obligation to do no harm.

At the very heart of the debate on assisted dying is the ethical principle of personal autonomy or self-determination of the individual, who may express refusal of medical treatment or specifically ask for assistance for dying; therefore, the issue of assisted dying presents a moral dilemma. The discussion of this moral dilemma first needs a clear understanding of the rights of the individuals arising out of the concept of personal autonomy. Autonomy relates to the right of the individual to direct their life according to the values they want their life to adhere to. Within medical ethics, decision making and autonomy are linked to each other in that the decision making itself is directed at safeguarding the patient’s endorsed perspective or values against the judgement of the medical professional (Gaster, Larson, & Curtis, 2017). There is also a wider interpretation of autonomy, which sees an individual have a place in humanity and have their wishes observed; in other words, we are autonomous because we are part of humanity (Gaster, Larson, & Curtis, 2017). In medical ethics, the principle of autonomy demands that the medical professional will help make patients or beneficiaries to come to decisions themselves and will take into consideration the beliefs, knowledge, and awareness of the individual (Beauchamp, 2007). When we speak about assisted dying, the principle of personal autonomy may require that those who wish to do so may request their medical professionals or carers to assist them in ending their life (Beauchamp, 2007). This principle of autonomy in the context of assisted dying, also has specific connections with human rights and social justice. This was demonstrated in the Pretty case, which was decided by the European Court of Justice (ECtHR) (Pretty v the United Kingdom, ECtHR judgment of 29 April 2002, 2002). The facts of the Pretty case were that Mrs Pretty was afflicted with a degenerative illness, for which there was no cure. She made a request in writing to the Director of Public Prosecution that he would not prosecute her husband for assisting her in ending her life because her state was degenerative in nature. This request was denied by the Director of Public Prosecution and upheld by English courts; her case to the ECtHR was in appeal from these decisions in the UK. The appeal in the Pretty case was made under Article 2 of the European Convention of Human Rights, which protects the right to life. Interestingly, the court denied appeal under Article 2, but allowed it under the right to personal autonomy protected in Article 8(1). Thus, while the court denied the appeal under Article 2 on the ground that language of Article 2 cannot be distorted to confer a “diametrically opposite right, namely a right to die” (Pretty v the United Kingdom, ECtHR judgment of 29 April 2002, 2002, pp. paras 39-40 ), Article 8(1) was still applicable to allow “personal autonomy” to Mrs Pretty so that she could exercise her personal choice and self-determination in this matter (Pretty v the United Kingdom, ECtHR judgment of 29 April 2002, 2002, p. para 67).

Therefore, while individuals may not claim the right to die in Article 2, they may claim their personal autonomy in Article 8(1) for coming to assistance in cases of terminal illnesses where a painful end of life is a given. The discussion in this paragraph can be summarised by noting that assisted suicide is linked to personal autonomy and self-determination of the patient and this has specific link to human rights.

The issue of assisted dying as a personal autonomy right may be complicated by the potentially conflicting values and ethical dilemmas for the medical professional in this situation; particularly, the respect for sanctity of life. This conflict between the personal autonomy of the patient who wishes assistance in ending their life and the doctor or medical professional who may have ethical stance on the respect for sanctity of life is one of the core issues in medical ethics related to assisted dying (Keown, 2006). The principle or ethical position of sanctity of life is opposed to the ethical position on quality of life. While sanctity of life focuses on the value that all life is sacred and therefore cannot be taken by human beings, the quality of life approach focuses on the life that the patient may enjoy if it is preserved. The principle of personal autonomy seeks to respond to the position of sanctity of life by arguing that sanctity of life cannot be preserved as against the wishes of the individual concerned (Samanta & Samanta, 2013). In the Petty case, the European Court of Human Rights did give precedence to the principle of personal autonomy of the patient, however an important question raised in the case by David Korff needs to be responded to in the context of the personal belief of medical professional; the question is whether the principle of autonomy can be a right to allow those who seek death to demand or require the assistance of others (Korff, 2008, p. 21). For the medical professional who may be asked to assist in the ending of life of such an individual, a key issue may be that of a personal or ethical belief in the principle of sanctity of life (Keown, 2002, p. 56). The important issue then would be how to reconcile the right of personal autonomy of the individual with the belief in sanctity of life. One approach to this is the argument that the view of sanctity of life must yield to the right of personal autonomy because even if the medical professional has personal beliefs in sanctity of human life, there may be someone else, a family member perhaps, who can assist the patient in ending life (Samanta & Samanta, 2013). This approach was taken in the Petty case, where the European Court of Human Rights held that the patient could ask for assistance from her husband to end life (Pretty v the United Kingdom, ECtHR judgment of 29 April 2002, 2002). The case of Anthony Bland may also be cited here because it indicates how life may mean different things to different people, so that when even sanctity of life argument is proposed, the counter argument of quality of life may be used (Airedale NHS Trust v Bland [1993] AC 789, 1993). In this case, Anthony Bland was in a permanent vegetative state for past three years but was considered to be still alive because “as a result of developments in modern medical technology, doctors no longer associate death exclusively with breathing and heartbeat, and it has come to be accepted that death occurs when the brain, and in particular the brain stem, has been destroyed” (Airedale NHS Trust v Bland [1993] AC 789, 1993, p. 865). Therefore, while in strict medical terms, it may be argued that a person is still alive because of medical innovation, it may even be counter argued that the person does not have any quality of life and may even not be alive were it not for medical assistance (Samanta & Samanta, 2013). In such as situation, an argument may be made in quality of life context to counter the sanctity of life approach.

The ethical and professional principles influencing decision-making in health and social care, including the principles of respect for autonomy and beneficence may be used to make an argument for allowing assisted death. There are four principles of medical ethics: respect for autonomy, beneficence, non-maleficence and justice (Beauchamp, 2007). Decision making in health care and the resolving of moral dilemma can be done with the help of these four principles. Medical professionals can use one or more of these principles for the purpose of decision making for the health and well-being of their patients. The principle of respect for autonomy has been discussed earlier in this essay and it relates to the respect for the freedom and choice and governance and rule of self (Beauchamp, 2007). The principle of beneficence focuses gives precedence to the benefit of the patient. The principle of nonmaleficence is based on the principle of non-harm contained in the maxim, primum non nocere (Above all, do no harm) (Beauchamp, 2007). The principle of justice is related to equitable treatment and fair conduct. In the present situation, the principle of beneficence may guide the medical or health care professional to consider the benefit of the patient asking for assisted dying before their own personal or ethical beliefs. The principle of respect for autonomy is already discussed above in the first paragraph, where the link between the right of autonomy of the patient and human rights was also drawn out with the aid of the Petty case (Pretty v the United Kingdom, ECtHR judgment of 29 April 2002, 2002). The principle of beneficence may now be considered at some length to make a case for assisted dying. The principle of beneficence is related to kindness, charity, and the feeling of mercy where the actor or decision maker is driven by the need to benefit others (Beauchamp, 2007). In the context of the principle of beneficence, the medical professional would be driven by the need to protect the patients in their “important and legitimate interests, often by preventing or removing possible harms” (Beauchamp, 2007, p. 5). To summarise this section, the medical professional may resolve his ethical dilemma in whether to respond to claims of sanctity of life or to respect the autonomy of the patient by applying the principle of beneficence. In this context, the medical professional may consider the protection of the interests of the patient who may be suffering from a degenerative or incurable disease by assisting the patient to end life.

My own values are predisposed to respecting the principle of autonomy and prioritising beneficence and principle of quality of life over and above sanctity of life. I do personally believe in the principle of autonomy because it is derived from the liberal moral and political tradition, which treats the rights of freedom and choice as essential to human life (Beauchamp, 2007). The principle of autonomy relates to decision taking and governance, wherein the individuals are considered to be free to take decisions for themselves without any external pressures (Beauchamp, 2007). I believe that when it comes to the decision of the patient to end life, it is first the decision of the patient. Cases like Anthony Bland, who was in a vegetative state for more than 3 years and still could not get assistance to end his life have made me more aware of the importance of the need to consider the benefit of the patient who is in that stage, the quality of life of the patient if he is preserved and the possible wishes of the patient if he had been in a state to make decisions for himself. I admit that the personal belief in sanctity of life may be derived from Christian beliefs and may make it difficult for those who are not able to assist in this area, be these medical professionals or carers (McLean, 2007, p. 30). I also admit that the courts in the UK have also underlined the importance of the belief in the sanctity of all human life (McLean, 2007, p. 30). However, I also believe that if consideration of the patient’s condition and beliefs are also taken into account, then it may be easier to resolve the ethical dilemma by allowing family or someone else to assist the person who wishes to end their life. In case of those who are mentally incapable of making these decisions, advance directives for healthcare can be provided in the law so that the autonomy of a person who has lost competence to make healthcare decisions can still be respected (Freckelton & Petersen, 2017). Such laws already exist in the Netherlands, and Australia and allow the doctors or health care professionals to give effect to the previously stated wishes of the patient (Freckelton & Petersen, 2017). Using similar approaches in other legal systems, the law can provide a framework within which the wishes of those who can no longer make decisions for themselves but who have already submitted in writing their desires for assisted death can be respected as per the principle of respect for autonomy. To summarise, it may be noted that while sanctity of life is an important ethical position, it cannot supplant the principles of respect for autonomy and beneficence. The interest of the patient also should be taken into account, for which the quality of life if preserved should be an important criterion.

To conclude, assisted suicide does involve a moral dilemma, but it is a moral dilemma that can be resolved by adherence to ethical principles, in particular, the principle of respect for autonomy, beneficence, and quality of life. A possible solution to the dilemma is to allow those medical or health care professionals who do not have strong positions on sanctity of life principle to assist in the death of a patient who has an incurable disease and is at an end of life. A legal framework that specifies the conditions under which such decisions can be taken would be useful. Such a legal framework already exists in countries like the Netherlands. Borrowing from such framework, while also using the social and political realities of a country like the UK may be useful in coming to a framework that may suit the UK. For patients who are not mentally capable of making such decisions, an advanced care directive framework can be adopted which allows people to make written directives stating their wish for assisted death.

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References

Airedale NHS Trust v Bland [1993] AC 789 (1993).

Beauchamp, T. L. (2007). The ‘four principles’ approach to health care ethics. In R. E.

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Freckelton, I., & Petersen, K. (2017). Tensions and Traumas in Health Law. Annandale, NSW: The Federation Press.

Gaster, B., Larson, E. B., & Curtis, J. R. (2017). Advance directives for Dementia: Meeting a Unique Challenge. JAMA, 318(22), 2175-2186.

Grenz, S. J., & Smith, J. T. (2003). Pocket Dictionary of Ethics. Downers Grove, IL: InterVarsity Press.

Keown, J. (2002). Euthanasia, Ethics and Public Policy: An Argument Against Legalisation . Cambridge: Cambridge University Press.

Keown, J. (2006). Restoring the Sanctity of Life and Replacing the Caricature- A Reply to David Price. Legal Studies, 26(1), 109.

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McLean, S. (2007). Assisted Dying: Reflections on the Need for Law Reform . Oxon: Routledge

Pretty v the United Kingdom, ECtHR judgment of 29 April 2002 (2002).

Samanta, J., & Samanta, A. (2013). Holistic determination for oneself: a new paradigm for self-determination at end of life. CLJ, 72(3).