BIOETHICS AND ITS APPLICATION IN VARIOUS HEALTH CARE

SITUATIONS JENELYN V. NAPURAN,RN,MSN

THE SANCTITY OF HUMAN LIFE

Is human life sacred?
This is the very fundamental question that we may ask ourselves to be able to
understand the underlying principle behind the sanctity of human life. We can
view the sacredness of the human life through a national or humanistic approach
or by the religious or theistic approach
Religious Approach
This states that human life has dignity and there is something sacred about it
because it comes from God (Judeo Christian tradition). Both the Catholics and the
Protestants believe that a man's life is entirely an ordination, a loan and
stewardship and emphasizes that God is the source and ultimate guarantor of the
sanctity of this life.
Rational/Humanistic Approach
These virtues that the idea of sacredness is generated by the experience of being
alive, of experiencing the elemental fear of its extinction and its sacredness is the
most primordial of experience.
For a sincere non-religious person, he or she may admit that there is a supreme
being that governs our lives, but for a totally non-theistic person, the sacredness
of life will be difficult to prove. Because it is true to say that there should be a
source of this life and did not only originate from our parents and even our
ancestors, but to a being that is pure in heart that has given us this special gift.
THE DUTY OF PRESERVING LIFE
As for all health workers who are facing different transitions in the delivery of
health care services to the people, their duties have not only moved to a different
level but also the perception of their duty to preserve human life has also
changed. As the situation changes and the development of different ways of
preserving the lives of the people through advance technology, upscale services
and even the
improvement of indigenous resources; health workers should be well guided by
the principle that underlies these acts of Altruism.
Law
Is defined as an objective norm of morality in ordinance of reason which
dictates actions for the common good and promulgated by legitimate
authority.
Kinds of Law
1. Divine Law is instituted by the will of God.
1.1. Eternal Divine Law - eternal plan of divine wisdom, e.g. Divine Providence.
1.2. Natural Divine Law - the participation of the rational being in the eternal
plan of God. e.g. Don't cheat, Don’t be selfish, Obey elders etc.
2. Human Law- has its immediate source of origin from human authority.
Civil law - law made by the state e.g. everyone must pay his due taxes, obey
traffic rules etc.
Canon law-laws instituted by the church e.g. attend mass every Sunday, love
God above all, etc
The Sacredness of Sexuality
Sexuality is a fundamental component of personality, one of its modes of being of
manifestations, of communicating to others, of feeling, of expressing and of living
human love. Feminity and masculinity are complimentary gifts, through which
human sexuality becomes an integral part of the concrete capacity for love which
God has inscribed in man and woman.
Sexuality characterizes man and woman not only on the physical level, but also on
the psychological and spiritual, making its mark on each of their expressions. Such
diversity, linked to the complementarity of the two sexes, allows thorough
response to the design of God according to the vocation to which each one is
called.
Three crucial truths stem from the theological reflection of the scriptural passages:

• That men and women are equal persons,

• That God is the author of marriage, one who give to if it's defining
characteristics,
• That men and women are persons with body and soul, not merely spirit
persons.
ISSUES ON SEX OUTSIDE MARRIAGE
a court in the United Arab Emirates have detained a foreign couple in their
twenties for having sex outside marriage and if found guilty they will both face a
lengthy jail sentence. Shortly after the 2017 General Synod vote in the UK on
whether same sex couples could be “blessed” in church, the eminent theologian
and academic Professor John Milbank tweeted: “There is no need to demand
“celibacy” in gay relationships. That wrongly equates same sex physical affection
with full (heterosexual) sex”.=
NATURAL LAW AND SEX - St. Aquinas and other Natural Law theorists would say
that our sexual faculties have one true end — procreation. True, sex is
pleasurable but it is pleasurable in order to fulfil this end. If this is correct then
sexual activity is good if, and only if, it is consistent with procreation and bad in so
far as it frustrates that end. Procreation is natural and other acts considered non-
procreation are immoral.
KANT AND SEX Kant thinks that sex is morally permissible within the context of a
heterosexual, lifelong, and monogamous marriage. Any sexual act outside these
contexts — homosexuality, masturbation, adultery, premarital sex — is morally
wrong. The basis of his general conception of morality is that actions are wrong
when we treat people disrespectfully . (Respect for Humanity)
SEX AND UTILITARIANISM - Utilitarianism does not rule out an act on the basis of it
being a particular act. This means that if Utilitarianism is correct we cannot say
that any particular sex act is always wrong. Premarital sex, or homosexual sex, or
masturbation, or oral sex can be morally acceptable. The matter is decided by
whether or not performing that act brings about more pleasure overall than not
doing so.
 CONVENTIONAL VIEW – sex is permissible between legally married man and
woman
LIBERAL VIEW – sex is permissible under basic standards that are moral (no one is
cheated or no one is harmed)
MODERATE VIEW – sex is permissible if the two consenting partners have an
emotional connection
The family is clearly identified as the basic unit of a community. Health care giver
in this regard should be equipped with the background on how a family works;
their culture, beliefs, orientation etc. So that, they will be able to design strategies
in rendering services to every client that he or she will encounter, both in the
Community and Hospital Setting.
Characteristics of Married Love
The encyclical Human Vitae lists the marks and demands of conjugal love
declaring that is:

• It is human love (physical and spiritual) –

• it is saying "yes" to someone else, and "No" to oneself. By it, husband and
wife become one heart, one soul and together attain their human
perfection.
• It is total.
A married person loves generously and shares of thing for undue
reservation or selfish calculations.
• It is faithful and exclusive.
The adjective committed describe how true married love involves a
pledging of oneself to another. Married love is not self-centered but looks
to the other partner.
• It is fruitful.
The matrimonial consent has two essential elements: Conjugal love, and the
ordination to children. All authentic conjugal Natal love between a man and a
woman, tends toward the creation of another being issuing from that love; it is
open to life.
Causes of Marriage: "What brings them together?"
One thing is the actual intention of the spouses, and the other is the purpose or
end of the institution itself of marriage.
1. Final cause (purpose of the institution): Primordially, it is the begetting and
upbringing of the children; Secondarily, it is the mutual help and companionship
to all implications. These are the two aspects of the purpose.
2. Efficient cause (the agent who brings it about): The spouses motivated by a free
decision to love each other for life, issuing into a formal and public declaration
(man lives naturally in society) of remaining together until one of them dies.
3. Formal or constitutive cause (what makes it a marriage): the mutual self giving
(or matrimonial consent) thus expressed and never withdrawn (neither of the two
has the right to do so if what they have entered into is a marriage union and not
just animal mating. )
4. Material cause the living bodies of the spouses, over which they acquire mutual
rights (not over the souls, strictly speaking, since the sphere of conscience remains
inviolable, although a closely knit spiritual and psychological mutual adjustment is
highly desirable).
Contraception
It is defined as the voluntary prevention of conception by the positive use of
artificial means which hinders the generative cells from uniting, during the sexual
act.
Methods of Contraception (Timbresa, Kippley Sloane)
1. Folk Methods
Pre-coital/post-coital douche
Vinegar and brine which are highly spermicidal substances are prescribe as pre
coital douche but some people experiences a burning sensation in the sensitive
membranes of the genitals so they then prefer post-coital douching which is
believed to flush out and immobilize the sperms in the vagina.
Another common and popular douche is with Cola-cola. The woman holds her
thumb over the open bottle, shakes the content on the bottle vigorously, inserts
the neck of the bottle in the vagina, removes her finger and allows the gaseous
contents to erupt inside the body. (Roserfeld)
Note: Douching maybe too late and often does not eliminate all the
semen. Prolonged lactation

It is believed that the prolongation of milk secretion or production in the mother's

mammary glands could delay ovulation as a result of the hormonal imbalance
occurring inside the mother's body.
Withdrawal (Coitus Interruptus)
This is withdrawing the penis from the vagina immediately, before ejaculation;
hence coitus is "interrupted" just prior to orgasm, and he makes ejaculation
outside the female organ.
Some couples finds this method very disturbing, and it may lead to sexual
dissatisfaction and irritability in sexual relations especially when the male insists
on withdrawal over the female, vice-versa. This kind of method is commonly
known to all couples as "interrupted melody".
Coitus reservatus
The male withholds ejaculation just before orgasm and allows the erection to
subside gradually, hence, coitus is "reserved" or "kept in reservation".
2. Mechanical Methods
Condom
Diaphragm
Sponge
3. Chemical Methods
Vaginal suppositories and tablets
Vaginal jellies, creams and foams
4. Hormonal Methods
Contraceptive pills
Injections and Implants
5. Abortifacients - Anything used to cause abortion or expulsion of the fetus.
Intrauterine device (IUD)- This is a small object made of plastic or stainless steel
and comes in various shapes and sizes. This in turn is placed or inserted inside the
uterine cavity. Pregnancy therefore is discontinued as it irritates and inflames the
lining of the uterus in such a way that the developing fetus that descends from
the fallopian tube, after it has been fertilized, cannot implant itself in the uterus
and eventually
dies. The disintegrated remnants which is also being mistaken as menstruation
comes out as the women's monthly period.
DES (Diethystilbestrol) - Also known as a morning after pill. It is a very strong kind
of hormone that forces the endometrium or uterine lining to shed. If the fetus has
already burrowed itself in the endometrium, it could still be destroyed.
Prostaglandins - A powerful drug, if taken orally, or by injection or by suppository,
causes a violent contraction of the uterus, that can expel out the product of
conception, the fetus then could be expelled out either dead or alive. If alive, the
fetus will eventually die due to prematurity.
Anti-pregnancy vaccine - This vaccine produces anti-bodies on the woman that
neutralizes HCG (Human gonadotropin hormone). If the HCG level drops, then the
woman menstruates and a miscarriage occurs. Hence, this induces the early
abortion of the fetus.
Low-dose type of contraceptive pills - This makes the endometrium not
sufficiently prepared for implantation. This is related to the damaged
endometrium; hence miscarriage occurs and the descending fetus flows with the
vaginal discharges.
ISSUES ON ARTIFICIAL REPRODUCTION, ITS MORALITY AND ETHICO MORAL
RESPONSIBILITIES
In Vitro Fertilization (IVF)- In Vitro means, "within a glass". Not only IVF known as
"laboratory fertilization" insofar as the fusion of the generative cells is done in the
laboratory, but it is also called "test tube fertilization" insofar as it is performed in
a petri dish or test tube. In other words, the technique of In Vitro Fertilization
involves conception outside the womb by artificial means, which is also referred
to as "procreation as sex" or "baby making as love making"
IVF Process. By means of a technique called laparoscopy, maturing ova are
extracted from the female ovary. The ovum is then placed in a petri dish or test
tube, where it's fertilized by the husbands' semen. After several days of growth in
the test tube, the fertilized ovum or embryo is implanted in the wife's uterus, and
if everything goes well, the embryo burrows itself in the endometrium (uterine
lining) and a normal pregnancy can be carried to term.
In the medical context, the IVF technique is done to overcome female sterility due
to obstruction of the fallopian tubes, which prevents the ovum from passing
through the oviduct (tube) where it meets the sperm and then descends to the
uterus for burrowing. Surgical removal of the blockage is very difficult, or in most
cases, impossible. Surgical extraction of ova, on the other hand, from the ovary is
possible, hence, IVF takes place. No person outside marriage is involved in the
product of fertilization, because the generative cells come from the husband and
wife themselves.
Other significant goals of IVF in the Medical Field:
1. to observe and evaluate the process of fertilization in Vitro, which is not
possible in the case of fertilization in utero.
2. to test the effectiveness of auto-fertility agents.
3. to evaluate the fertilization of the ova of patients with infertility problems.
4. to assess the structural and biochemical normality of the conceptus in patients
who have repeated spontaneous abortion.
5. to better understand the mechanisms needed for genetic studies.
6. to advance the understanding of normal and abnormal cell growth and
differentiation, and;
7. to increase knowledge that is useful in contraceptive technology an in the
alleviation of genetic disorders and other deformities.
Surrogate Motherhood - "Surrogate" means substitute, from the Latin
"surrogatus" or in place of another. This is a biomedical technique whereby a
fertilized ovum is implanted into the uterus of another woman, who will carry the
baby to term either as a favor or for a fee. It is precisely because of the financial
arrangement involved that this procedure is often referred to as the "womb for
hire," "rent a womb," or "uterus for rent" business. In such cases, a woman who
can produce normal ova, but whose health would be endangered by pregnancy,
can have her ovum fertilized by her husband's semen either in Vitro or Vivo and
after 3-5 days of growth, the embryo could be transferred to the uterus of a
healthy woman, who either out of friendship or for payment, would carry it to
term. After delivery, per agreement, she would give the baby to the couple who
are genetic parents of the child
ARTIFICIAL INSEMINTATION
In artificial insemination, a doctor inserts sperm directly into a woman's cervix,
fallopian tubes, or uterus. The most common method is called "intrauterine
insemination (IUI)," when a doctor places the sperm in the uterus . Why is this
helpful? It makes the trip shorter for the sperm and gets around any obstructions.
The doctor will use ovulation kits, ultrasound, or blood tests to make sure you're
ovulating when you get artificial insemination. Then, your partner will need to
provide a sample of their semen. The doctor will suggest that your partner avoid
sex for 2 to 5 days before the procedure to help make sure their sperm count is
high.
Your partner may be able to collect a semen sample at home. If not, they'll do this
in a private room. The sperm must be "washed" in a laboratory within 1 hour of
ejaculation. The process of "washing" the sperm in a lab removes chemicals in the
semen that may cause discomfort for a woman, and raises the chances of getting
pregnant. Technicians liquefy the sperm at room temperature for 30 minutes and
add a harmless chemical to separate out the most active sperm. They use a
centrifuge to collect the best sperm. Those are placed in a thin tube called a
catheter and put through your vagina and cervix into the uterus.
Artificial insemination is short and relatively painless. Many women describe it as
similar to a Pap smear. You may have cramping during the procedure and light
bleeding afterward.
 Morality of Abortion, Rape and other Problems Related to
Destruction of Life
Human life is sacred because from the beginning, it involves the creative action of
God and it remains forever in a special relationship with the Creator. So when we
encounter human life either in ourselves or in others we meet something filled
with majesty and dignity; something which calls forth a fitting response from us.
We owe human life respect and reverence. Such reverence, respect and concern
for life is a way of saying "Yes" to human life in all it's forms. Such a response of
"yes to life" is an echo of the "Yes" which God makes to human life.
What is abortion?
It means the expulsion of a living fetus from the mother's womb before it is viable.
"Abortion is defined as the termination of pregnancy, spontaneously or by
induction, prior to viability.”
Article II, Section 12 of the 1986 Philippine Constitution provides: "The state
recognizes the sanctity of life and shall protect and strengthen the family as a
basic autonomous social institution. It shall equally protect the life of the mother
and the life of the unborn from contraception.
What usually happens is that abortions are performed outside by illegal
abortionists, and when the woman suffers from profuse vaginal bleeding, she
goes to a hospital for confinement. She is admitted because of uterine
hemorrhage and not because of abortion, hence, there is difficulty in prosecuting
illegal abortionists. No woman in her right mind could ever admit to having
undergone an abortion.
The aforementioned facts and figures indicate that Filipinos practice abortion,
though illegal, and in spite of the Catholic Church's prescription or teaching
against it.
TYPES OF ABORTION
SPONTANEOUS ABORTION
THREATENED ABORTION
IMMINENT ABORTION
COMPLETE ABORTION
INCOMPLETE ABORTION
MISSED ABORTION
HABITUAL ABORTION
INDUCED ABORTION

Moral and Ethical Point of View

The direct and voluntary killing of an innocent human being is always gravely
immoral, even when it is performed as a means to a good end. In order to
highlight its moral evil, ecclesiastical law expressly punishes abortionists. All the
participants, including the mother, automatically incur communications. The
magisterium of the church has consistently condemned abortion throughout
history, even when the exact moment of the fetus animation was being disputed.
Respect for human life and radical condemnation of abortion as intrinsically evil is
not an exclusive position of Catholics. All men of upright judgment share this view,
which is based on what a person is and should be. But in some persons this moral
stance has been obscured by the alleged negative consequences of rejecting
abortion, (medical, eugenic, economic, or social evils). All these false reasons
violate the basic principle of any view on human life: Life is sacred from the very
first moment of conception. In any case, life is a form of good of a higher nature
than those alleged in defense of abortion.
Respect for the person and scientific research
Research for experimentation on a human being cannot legitimize acts that are in
themselves contrary to the dignity of a person or a moral law. The subject's
potential consent does not justify such acts. Organ transplants are not morally
acceptable if the donor to those who legitimately speak for him have not given
their informed consent. It is morally inadmissible directly to bring about the
disabling mutilation or death of a human being, even in order to delay the death
of other persons.
 Respect for health
Life and physical health are precious gifts entrusted to us by God. We must take
reasonable care of them, taking into account the needs of the other and the
common good. Concern for the health of its citizens requires that society help on
the attainment of living conditions that allow them to grow and reach maturity:
food and clothing, housing, health care, basic education, employment and social
assistance.
Respect for Bodily Integrity
Kidnapping and hostage taking are morally wrong. Terrorism is gravely against
justice and charity. Torture is contrary to respect for the person and for human
dignity. Except when performed for strictly therapeutic medical reasons, directly
intended amputations, mutilations, and sterilizations performed on innocent
persons are against the moral law.
Abortion under the law
A. Legislative motives
Laws that permit abortion with a maximum time limit. This states that abortion is
possible up to a certain stage during a pregnancy and is essentially at the woman's
request. Laws that allow abortion only for medical reasons.
- Abortion is not simply a matter of a woman asking for it. It may only be
performed legally if there are particular circumstances.
Laws that prohibit abortion.
It include laws that completely prohibit induced abortions, or only allow them in
very exceptional circumstances, e.g. saving the mother's life.
Note: In the Philippines, abortion is illegal, but is a clandestine practice. Article III,
Section 12 of the 1986 Constitution provides: "The state recognizes the sanctity of
life and shall protect and strengthen the family as a basic autonomous social
institution. It shall equally protect life of the mother and the life of the unborn
from conception."
B. Ethics of Legislation:
For legislation to be ethically acceptable, it is not enough for it to go through the
legally correct process of drafting and approval. Observation of procedures only
provides judicial legitimacy; only justification from the point of view of the
common good can invest it with moral value.
The task of laws is to protect the rights of human beings, especially the most basic
rights, and even more particularly the rights of the most defenseless individuals
What was solely of interest until recently was the so-called criminal abortion,
considered a grave crime in Penal Codes. Today, with the legislation and positive
authorization of abortion in some cases, things have changed.
A review of the legal proceedings of those countries which have legalized abortion
show some differences in modalities, which can be observed upon reading the
World Health Organization (WHO) chronicle of 1976. This chronicle summarizes
the conditions or situations in which the legislation of different countries
authorize the practice of abortion:
• When the mother is authorized to safeguard her physical and mental health. •
When pregnancy is the consequence of rape or incest, or occurs in minors. •
When the mother contracts sub-cola during a critical stage of gestation (with
consequent risk of congenital malformation of the baby) or has been
exposed to other risks (e.g. certain drugs or ionizing radiations) which can
lead to defective fetal development.
• When Down's Syndrome or other chromosomal abnormalities are diagnosed
by amniocentesis;
• When the parents are mentally-deficient and considered incapable of
Dignity in Death and Dying

Death is more complicated than it used to be, it is a time of ethical conflict. The
moral issue of euthanasia revolves around the preservation of human dignity in
death even to the individual's last breath. This issue has a positive and negative
side.
a. Positive - states that euthanasia aims to preserve human dignity until death.
Not only does one have a duty to preserve life but one has also the duty to die
with dignity. To die with dignity means that one should be able to make the
decision to die when dying would be better than to go on living with an incurable
distressing sickness.
b. Negative - declares that euthanasia erodes human dignity for it is cowardliness
in the face of pain and suffering. People who have faced the realities of life with
courage dies with dignity.
Euthanasia - derives from the Greek word eu (good) and thanatos (death). It
etymologically signifies good death, a pleasant, gentle death, without awful
suffering. Euthanasia may be defined as an action or omission, that by its very
nature, or intention, causes death, for the purpose of eliminating pain.
The word was used for the first time by F. Bacon in 1623. He affirmed "that the
task of the physician is to bring back health, to mitigate suffering and pain not so
much in that this mitigation can lead to a cure, but it may also serve to procure a
peaceful and easy death (euthanasia)". The word is used today to signify that
procedure which facilitates death and liberates from all types of pain, provoking
the death of the hopeless patient and suppressing "useless human lives.
Kinds of Euthanasia
1. Suicidal Euthanasia - When the subject himself (a love or with the help of the
others) resorts to lethal means to interrupt or suppress his life. Therefore, it is
done with the subject's consent.
2. Homicidal Euthanasia –
2.1 Euthanasia for Piety (Pious homicide) is performed to liberate a person from a
terrible disease, agonizing senility, etc. Today this type of euthanasia is presented
as the most "reasonable" compared to other types. "Death without suffering for
hopeless patients, saving them from "useless", "unnecessary" suffering.
3. Ortothanasia - Etymologically, the word ortothanasia means normal death The
subject is left to die by omitting any medical assistance. But for some authors, this
terminology has other meanings (just death, death in due time) which are
considered ethical.
4. Positive or Negative Euthanasia
Positive euthanasia provokes death through adequate intervention (equivalent to
suicidal and homicidal euthanasia).
On the other hand, negative euthanasia, is the result of omitting necessary
medical support, i.e. ortothanasia.
5. Active (Direct) euthanasia and Negative (Indirect) euthanasia - There is a
growing tendency today to impose the terminology. "Active or direct euthanasia"
to mean "euthanasia", properly speaking (to procure death in order to eliminate
pain). Negative or Indirect euthanasia, seeks to alleviate a patient of his sufferings
with the accompanying risk of shortening his life.
Views on Euthanasia
T. Gary Williams considers euthanasia to be morally wrong because:
1. It is intentional killing and opposes the natural moral law or the natural
inclination to preserve life.
2. Euthanasia may be performed for self-interest or other consequences.
3. Doctors and other health care professionals may be tempted not to do their
best to save the patient, they may resort to same euthanasia as an easy way out
and simply disregard any other alternative.
James Rachels opts for euthanasia, believing it to be humane insofar as it allows
suffering to be brought to a speedy end. In his view, whether killing of any kind is
right or wrong depend on the motives and circumstances under which it takes
place. "If you help an agonizing, medically hopeless patient to die painlessly you
will be doing him/her a favor and it would be wrong and inhuman to prolong the
patient's suffering needlessly.“
Philippa Foot endorses both active and passive euthanasia, in which the patient
explicitly gives consent. In her view, everyone has a right to life, hence it is what a
person wants that counts.
Dysthanasia: what is it?
Although less disseminated than euthanasia, dysthanasia is, unconsciously, most
practiced. Although opposite, both are ethically condemned for because, roughly
speaking, one anticipates the death of a person still alive and the other extends
the life of a person already dead. Despite the difference, as affirmed by Pessini,
they cause death unexpectedly. The concept of dysthanasia, proposed initially by
Morache in the book “Naissance et mort”, is etymologically derived from the
Greek and it results from the prefix dis, distance, wrongly done, and the
substantive thanatus, death. Dysthanasia, therefore, refers to digression of death,
the botched
death, a difficult death or, more precisely, under Brito and Rijo’s perspective ,
extending a patient’s life beyond his natural period. Such definition apparently
simple raises complex questions on what life is and on quality of life.
In dysthanasia one resorts to totally excessive care in view of the benefits that
may be obtained. A care or treatment may be considered unreasonable or
disproportionate to the extent that it does not supplant the benefit and, here,
respecting the ill-person’s autonomy, he shall decide about the continuity of his
treatment. But the proportionality of a treatment must always be contextualized
according to the ill-person, his wellbeing, dignity, and his death in peace, and not
on factors external to him.
Basically, all alternatives are used to the life of a human being’s life, even if
healing is not possible (yet) and suffering and anguish become unbearable.
The ethical principles that underpin dysthanasia practices or its negation are very
interwoven: dysthanasia underlines the ethical principle of beneficence that can
be understood as the self-respect transposed to third parties and that defines
good and determines that it be accomplished , what underlies a medical
commitment to engage all feasible efforts and technical means to keep the
patient alive.
The denial of dysthanasia has the principle of non-malefecence underlined,
related to the primum non nocere maxim, as part of the principle that any
therapeutic intensification only prolongs or increases the ill-person’s suffering
ADVANCE DIRECTIVES
In 1983, at twenty-five years of age, Nancy Cruzan lost control of her car and was
thrown into a ditch. Although she was resuscitated at the scene of the accident,
she never regained consciousness. Like Karen Ann Quinlan, Nancy was diagnosed
as being in PVS, and physicians estimated that she could live for another thirty
years being supported by feeding tubes. An describing her condition, her father
stated that "Since the accident, she has never had what we felt was a thought-
produced response to anything. We feel the most humane and kind thing we can
do is to help her escape this limbo between life and death. Given the prognosis,
the family requested that the feeding tube be removed and Nancy be allowed to
die. When the Missouri Rehabilitation Center refused the request, the family took
the case to the lower courts, which ruled in their favor. This affirmation was
overturned by the
State Supreme Court on the basis that the state's greater duty to preserve life
outweighed any right that the parents might have to refuse treatment for their
daughter.
In December 1989, the Cruzan case became the first of the right-to-die cases to be
heard by the Supreme Court of the United States. In its decision, the Court upheld
the Missouri Supreme Court position that not even the family should make choices
for an incompetent patient in the absence of "clear and convincing evidence" of
the patients' wishes. In a five four decision, the Court ruled that states do have
these rights for the following reasons:
• The state has a right to assert an unqualified interest in the preservation • A
choice between life and death is an extremely personal matter of human life.
• Abuse can occur when incompetent patients don't have loved ones available
to serve as surrogate decision makers.
• The state has a right to express an unqualified interest in the preservation of
human life.
To accommodate the clear and convincing evidence standard required by the
court, three friends of Nancy came forward claiming to have had conversations
with her prior to the accident in which she expressed the conviction that she
would never want to live the life of a vegetable. As a result, the State of Missouri
no longer opposed her parents in this action and the feeding tube was removed.
Nancy Cruzan died shortly after the removal.
The call for clear and convincing evidence in regard to these cases has increased
the interest in advanced directives.
DNR ORDERS (DO NOT RESUSCITATE)
Cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) are
interventions that could theoretically be offered to all patients within the hospital.
By the 1970s, it became obvious that it was not in the best interest of certain
patient groups to be resuscitated, and hospitals began to initiate policies
governing DNR (Do Not Resuscitate) orders.
DNR policies are now required of all hospitals by the joint Commission for the
Accreditation of Health Care Organizations.
The initiation of DNR orders is best performed after an understanding by
physicians, patients, family, and staff has been reached. This is an area in which
value preference will make a great deal of difference. In one case where the
physician was attempting to broach the subject of placing a DNR order, he began
by telling the patient that if he had another event, the chances of CPR being
effective would be one in a thousand. The patient replied by asking a question in
regard to his chances if CPR were not initiated. This patient wanted what ever
chances there might be and wasn't interested in statistics. Although
patient/provider discussion in regard to DNR orders would, in theory, facilitate
autonomous control by the patient, research has consistently shown that only
about 20 percent of the patients with DNR orders discussed their resuscitative
preference prior to the order being implemented.
CONSIDERATIONS IN DNR
1. DNR orders should be documented in the written medical record. 2. DNR
orders should specify the exact nature of the treatments to be withheld.

3. Patients, when they are able, should participate in DNR decisions. Their
involvement and wishes should be documented in the medical record.
4. Decisions to withhold CPR should be discussed with the health care
team. 5. DNR status should be reviewed on a regular basis.