Euthanasia, or voluntary assisted suicide, has been the subject of much moral, religious, philosophical, legal and human rights debate around the world and St Lucia is no exception. Each time an incident of that nature arises, it raises the debate among many St Lucians, some in support and some against the practice.
According to the online medical dictionary, euthanasia is defined as follows:
“The act or practice of ending the life of an individual suffering from a terminal illness or an incurable condition, as by lethal injection or the suspension of extraordinary medical treatment.”
In many other terms, euthanasia is also referred to as “physician assisted suicide.” It is widely accepted in clinical ethics that removing a patient from a ventilator at the patient’s request is ethically permissible. This is often termed voluntary passive euthanasia (VPE), although there is controversy over this terminology and in particular over the idea that ending a patient’s life in this way is any less direct than other means.
Conversely, voluntary active euthanasia (VAE), such as giving a patient a lethal overdose with the intention of ending that patient’s life, is ethically proscribed, as is assisted suicide (AS), such as providing a patient with lethal pills or a lethal infusion. Proponents of VAE and AS have argued that the distinction between killing and letting die is flawed, and that there is no real distinction between actively ending someone’s life and “merely” allowing them to die.
But hey, before we can delve into the meat of the matter, may I indulge your intellectual appetite in a bit of medicine. A number of serious illnesses or injuries can lead to respiratory failure. This condition is characterized by the inability of the heart and lung systems to maintain adequate tissue oxygenation and to remove carbon dioxide from the lungs. Respiratory failure is a critical condition requiring immediate emergency treatment to prevent death.
Long-term illness, traumatic injury, severe infection, and brain injury and disorders may contribute to respiratory failure. Respiratory distress usually precedes respiratory failure and is noted by increased heart rate and adverse changes in breathing rates and patterns. In the majority of cases, the event that precedes respiratory distress is an airway obstruction.
When signs of respiratory distress are observed in a hospitalized patient, emergency personnel are alerted. If the distress cannot rapidly be brought under control, the patient is transferred to the intensive care unit (ICU) for additional care. The ICU is a high cost operated area of almost all hospitals if not most and critically demanding of hospital resource personnel particularly for small countries such as St Lucia.
When the patient “codes,” i.e., stops breathing, a mask connected to a bag containing air and extra oxygen is placed over the face and pressure is used to force air into the lungs. If the patient cannot breathe without assistance, a slender endotracheal tube is inserted into the mouth and guided down the airway into the lung. This procedure is termed “intubation.” The tube is then attached to a ventilator machine whose main function is to “ventilate” the body, i.e., to remove the waste product carbon dioxide, from the lungs. With the initiation of mechanical ventilation, the doctor, patient, and family members should begin a regular dialogue regarding treatment options and progress.
Modern computerized ventilators enable the patient to “come off the ventilator” as soon as possible. Weaning from mechanical ventilation entails a transition period from total ventilatory support to spontaneous breathing but that also is dependent on many factors. Doctors would need to take into consideration what circumstances brought on the need for a ventilator and should the ventilator be removed, will that patient have the ability to breathe on his or her own?
Now you are ready, dear readers, to analyze the case of Sherwin Poleon who this week died from a brain injury after a decision was taken to remove him off the ventilator. According to the family, Neurologists in Barbados and Trinidad both concurred that it would be impossible for someone who has sustained such injury to recover. Any medical student or doctor would know the basic facts of the brain. The brain is the only organ in the body where its tissue cannot regenerate after injury.
Dr Andre Matthew, a medical practitioner and current public relations officer of the St Lucia Medical and Dental Association, agrees that in cases where the vital parts of the brain has been compromised; injury related to that area is considered to be permanent unless some scientific technology such as stem cell research is developed to regenerate damaged tissue.
“The brain controls all the vital organs of the body and there are some parts of the brain where injury may occur and yet you will live infirmed or you may live with paralysis or whatever the case may be. Now there are parts of the brain where you know a patient will not live. Such parts include what would regulate the heartbeat, respiration and temperature. There are parts of the brain where you know if you if it ceases to function, the organs will go haywire.
“So essentially, that detail of knowing what or where the brain injury is determines whether or not you know the patient is fatally injured and you’re just keeping them alive knowing there is nothing that could be done. Human intervention really is the only thing keeping that person alive because the part of the brain that is essentially responsible for breathing and heart rate has been permanently damaged, so the ventilator is the only thing keeping that person alive by taking over the function of the brain. Taken off, that person would die because brain cells do not regenerate or repair itself,” said Dr Matthew.
He further stated that there are other factors involved in deciding whether or not a patient can be removed from the ventilator which are related to operational resources at hospitals and incoming patients with a greater survival rate.
“There are other people who may be in a better circumstance who need to use that same facility. Someone who comes in with a severe asthma attack and would benefit from the use of a respirator for a few days—should that person be refused because of a terminally ill patient who has little to no chance of living, the outcome can be fatal where as he or she could have survived. So you may have a case where both patients would die instead of saving one. You won’t keep someone you know won’t make it for someone you know will, particularly if the hospital only has two ventilators and a limited number.
“So I think it is much more than a moral and ethical question. It really becomes a moment decision kind of thing based on the resources and facts available to the hospital.”
Meanwhile, on a religious standpoint, given the fact that Sherwin Poleon was a member of the Seventh-Day Adventist Church in St Lucia, President of the St Lucia Mission of Seventh-Day Adventist, Pastor Johnson Frederick says the church, in this specific circumstance agrees and supports the decision of the family to remove Sherwin off of the ventilator.
“The issue of euthanasia is ethical in nature but as a church it has spiritual implications. First of all, I want to put a distinction between mercy killing and relieving someone by withdrawing medical intervention that they prolong suffering. Not necessarily life per say, but prolonged suffering.
“We do not support helping one to commit suicide. I think this is both immoral and unethical but we do support families who decide that through human medical intervention, that life is prolonged and thereby suffering. Such persons should be relieved by a family member in whose care the dying person is making the decision to withdraw that person from any life supporting apparatus.
“This is not suicide but intervening to end suffering and you are not ending life either because in the first place the person is continuing to live because of human intervention. On his or her own, she dies. So I think it is morally correct and ethically accepted that upon the advice of the doctors in a case where there is no hope of recovery to end human intervention which only prolongs suffering and prolong grief for the family,” said Pastor Frederick.
In many cases, some patients would choose to have an advanced directive particularly the ones who are scheduled to undergo brain or heart surgery.
These patients believe that should something go wrong, they would not like to remain in a vegetative state but would rather choose to die. They would sign a “Do Not Resuscitate” form or living will which does not permit for human intervention should the code or slip into a coma. Advance directives can also be signed where patients would give a trusted family member the power to make decisions on their behalf should they lose the
ability to do so during and after surgery.
Although in this case, no such forms were signed by the patient, the mother automatically has that right to make the final decision for her child because he is below the age of eighteen.