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Euthanasia is a term that refers to ending a life in a manner that eliminates pain, suffering, discomfort, or the inability to engage in reasonable life experiences prior to natural death. In the United States, there are additional definitions of euthanasia that include intentionally withholding a life-saving medical procedure (passive euthanasia), or assisting a patient or loved one in their own death (criminally assisted euthanasia). The practice remains an extremely controversial one, and takes into consideration numerous topics that are philosophical in nature: quality of life, a person's right to choose their death (e.g. knowing they will become debilitated), and what constitutes a painless or "happy death" (Borry, Schotsmans, and Dierickx, 2006).

Historical Paradigm- In the Ancient World, specifically Greece, Rome, and Egypt, society believed that if a person had no interest in continuing their life, then society had no bond to force them to continue it. In the Christian dominated Europe after the fall of Rome, suicide as well as aiding in such was a criminal act. In the 1930s, non-voluntary euthanasia was practiced by the Nazi regime in order to eliminate diseased, disabled and undesirable people (handicapped, etc.). In the 1930s, organizations like the Voluntary Euthanasia Society and Hemlock Society were established to aid in the awareness, education, and eventual legalization of voluntary suicide and assisted suicide. The issue became a media frenzy in the late 1990s when Dr. Jack Kevorkian was imprisoned for assisting in the euthanasia of a patient in the final stages of ALS disease. Kevorkian subsequently served eight years in prison but claimed assistance in over one-hundred other cases (Sandhyarani, 2009).

Contemporary Viewpoints - Medical science has now progressed to the point where certain heroic measures can keep the body functioning. Unfortunately, this does not always mean that the quality of life, or the min, is also functional. Besides Dr. Kevorkian, the polarization of the issue reached international attention in the case of Terri Schiavo. Schiavo was diagnosed as being in in a persistent vegetative state, causing her husband to petition the Court to remove her feeding tube. This was opposed by Terri's parents and a host of other conservative and pro-life movements, including President George W. Bush. In total, the Schiavo case involved 14 appeals, numerous motions, petitions, and hearings in Florida, and five in Federal District Court, the Florida Supreme Court, Federal legislation, and four denials of certiorari from the U.S. Supreme Court. Finally, after 15 years of legislation, the local Court's decision to disconnect Terri was carried out in March, 2005 (Goodman, 2009).

The Pro-Euthanasia Arguments can be summarized as dealing with the rights of the individual and the idea that living and life are not synonymous:

Legalizing euthanasia would help alleviate the suffering of the terminally ill. It would eliminate their pain and lengthy time for demise.

A person has the right to choose what is best for them; individual rights should be an extension of natural rights.

Passive euthanasia has been part of the human paradigm since recorded history; it is a misplaced morality that makes it illegal.

Healthcare cannot "fix" everything; life on a feeding or breathing tube is, for some, not life (Information for Research on Euthanasia, 2009).

The Anti-Euthanasia Arguments, however, do not distinguish between types of killing - mercy killing, to them, is still homicide. Suicide is still altering the natural process of life:

Human life deserves exceptional protection. Hospices and institutions in which a patient can be made comfortable are preferable to euthanasia.

Medical science has advanced. but cannot predict remission or recovery; seemingly miraculous recoveries have taken place long after all hope had been lost.

Mercy killing would case decline in medical care, victimization of the most vulnerable in society, and provide a resurgence of eugenics (Overview of Arguments Against Euthanasia, 2010).

Ethical Dilemmas - At the very center of the debate on euthanasia lies the core of individual and societal ethics. Ethics is a philosophical concept that attempts to explain the moral organization within a given chronological time and cultural event. It is more concerned with understanding the way that ethnical ideas are presented, than judging those concepts within the construct of the society. It is important to note, however, that differing concepts of philosophy often arise "out of" that very historical and cultural fabric of the time - and then evolve so that they become more acceptable to future generations rather than contemporaneous ones (MacIntyre, 2006).

Even prior to the formalization of the terms utilitarianism and deontology, the core ideas of each have been debated for centuries. The Ancient Greeks argued over the needs of the individual as opposed to the needs of the. Showing just how much this concept has permeated popular culture, the philosophical issue even made it to the motion picture screen and was given a popular treatment in the science fiction movies Star Trek 2 and 3. [1 ]

Euthanasia and Utilitarianism - Utilitarianism holds that the most ethical thing one can do is any action that will maximize the happiness within an organization or society. At the center of this debate is the notion that many remain dissatisfied with the definition of "good" or "appropriate" being at the whim of a particular social order, or ruling elite. This debate may be found in Aristotle, Socrates, and Aquinas, leading to more contemporary political notions from Lock, Kant, and even Martin Luther King, Jr. Forming the core modern argument, for instance, Aquinas argued that there were certain universal behaviors that were either right or wrong as ordained by the Divine. Hobbes and Locke differed, and put forth the notion that there were natural rights, or "states of nature," but disagreed on the controlling factors of those natural tendencies. Kant took this further, reacting, and argued that a state or society must be organized by the way laws and justice was universally true, available, and, most importantly, justified by humanity. Yet, for Kant, these laws should respect the equality, freedom, and autonomy of the citizens. In this way Kant, prescribed that basic rights were necessary for civil society, and becomes a rubric by which we may understand modern utilitarian principles and their interdependence with the concept of human rights (Haydn, 2001).

Actions have quantitative outcomes and the ethical choices that lead to the "greatest good for the greatest number" are the appropriate decisions, even if that means subsuming the rights of certain individuals (Troyer, 2003, 256-52). It is considered to be a consequential outlook in the sense that while outcomes cannot be predicted the judgment of an action is based on the outcome - or, "the ends justify the means" (Robinson and Groves, 2003).

Deontology is a compatible, but alternative ethical system that has its roots in Ancient Greece, but is most often attributed to Immanuel Kant, a German philosopher writing about a century prior to Mill and Benthem. In utilitarianism, the focus is on outcomes, or the ends of an action; in deontology the actions themselves must be ethical and moral, or the outcome is moot. Deontology argues that there are norms and truths that are universal for all humans; actions then have a predisposition to right or wrong, moral or immoral. Kant believed that humans should act, at all times, as if their individual actions would have consequences for all of society. Morality, then, is based on rational thought and is the direction most humans innately want. Roughly, deontology is "the means justify the ends" (Kamm, 2007).

A classic illustration comparing the two ideas has you as a Police Captain managing a situation in which a sniper is shooting individuals who pass by a busy downtown square, apparently at random. The police have cornered the shooter and have their own sharpshooters ready for a kill shot. However, the shooter grabbed a child and is using her as a human shield. Do you authorize your own snipers to take a shot, knowing there is a chance of killing the child; or wait and risk the shooter killing more pedestrians? Certainly, the human shield did not "wish" to die, but then neither did the hundreds of potential victims on the street and in office buildings surrounding the shooter. If you take a utilitarian approach you give the order to shoot and hope the child is missed - if you take the deontological approach you hold that child's one life in the same reverence as the public's good.

Obviously, neither answer is completely right nor wrong - but situationally dependent, which would be anathema to both Kant and Mill, who saw the world in much clearer terms. What if, for instance, the child will grow up to discover the cure for cancer and thus save millions of people? However, what if the person who might be the next President and develop a global peace accord is in the building across from the shooter giving a presentation and is randomly shot?

Ethics in Modern Nursing - The philosophical combination of advocacy and ethics, while still remaining true to the realities of budgets and the need for a medical institution to make a profit, is a contemporary nursing issue comprising three essential attributes, respect for patient value & individuality, education of patients, and cognition and respect for the realities of contemporary medicine. During the diagnosis and initial opinion period, there are several events that will necessitate the nurse acting on behalf of the patient because of the patient's inability to either act or understand the procedure. Thus, the nurses' role as an advocate is to facilitate, encourage or to enable patients to be involved in all aspects of their healthcare, and when unable to do so, act in their stead (Burkhard, 2007).

Due to a number of social and cultural factors, and the increasingly complex role the nurse has within the healthcare model, nursing ethics has risen to its own discipline, a branch of applied ethics. Nursing ethics has many philosophical principles in common with medical ethics - beneficence, non-maleficence, and respect for autonomy - but can be more properly distinguished by its emphasis on relationships, maintaining dignity, patient advocacy, and collaborative care. Instead of using the model of "curing," nursing ethics focuses more on caring, and in turn, the relationship between the nurse and the person in care (Galadher, 2003).

The overall trend in nursing ethics, then, surrounds a more deontological than utilitarian approach (the means are more important than the result). The combination of ethics of care and virtue ethics support relationships more than philosophical debate (Tschudin, 2003). Thus, within the framework of this care model, we find that there are seven major ethical paradigms that guide the process of ethical care and specific determination of actions: autonomy, justice, fidelity, beneficence, veracity, non-maleficence, and paternalism.

Autonomy - The concept found in moral and bioethical philosophy that allows a rational individual to make an informed, un-coerced decision. One must be responsible for one's own actions, and the decisions one makes must be respected by others. Despite the expounding and development of this idea by Immanuel Kant, within medicine, respect for the autonomy of patients is an important goal, but it can, at times, conflict with beneficence. Within the healthcare field, this central premise of informed consent, particularly after the horrors revealed at the Nuremberg Trials ensures that the patient's understanding of the procedure be at the heart of all care; and if the patient is unable to understand, then an adult member of the designated family (Rai, 2009).

Justice - Justice in medical ethics focuses on fairness and equity in the allocation of limited healthcare resources. It represents the idea that people should receive healthcare based on their individual need, not on entitlement based on class, wealth, race, age, or other factors unrelated to their illness. Societal values, of course, reflect how decisions are made in regard to triage of resources, but the extreme of utilitarianism and deontology are less important as the thinking process in regard to fair care based on medical need (Edwards, 2003, 156).

Fidelity - In its basic form, fidelity refers to a truthful connection between source and response; loyalty, and the broad sense of dedication to a patient's needs. In modern healthcare, fidelity extends beyond the patient; the medical professional must be faithful to colleagues, the organization, their training and oath, and to society. This belief echoes Zerbi, a Renaissance philosopher and healer in that, "the doctor is the faithful companion of the body of his patient, suffers with him, and rejoices in his health. To neglect him, to act improperly in his home, to do anything prohibited by common morality or special medical ethics would be to break faith with the patient" (Jonsen, 2000, 49).

Beneficence - At the core of medical ethics is the value of beneficence, which provides the primary goal and rationale of medicine and healthcare - the core of the Hippocratic Oath - "as to disease, make a habit of two things- help, or at least do no harm." Part of the necessary rubric of healthcare, beneficence is not a dichotomous dictum - there are gray areas. For example, does one embark on chemotherapy treatment for a patient in their 90s with inoperable lung cancer versus if that patient were in their early 40s? Thus, beneficence must take into account the best decision for the individual's circumstances ((Edwards, 153).

Veracity - In medical ethics, veracity is part of the relationship of trust between the healthcare professional and the patient. Honesty and truth in what the healthcare professional shares with the patient are now expected - and the relationship is reciprocal - the healthcare professional expects the patient to be honest and truthful about concerns, attitudes, and information regarding the physical or mental symptoms in question. In addition, there is the expectation that any information given will be treated in a confidential manner (Johnson, 1998, 196).

Non-maleficence - The principle of non-maleficence not only asserts an obligation not to harm intentionally, but an additional obligation to use any and all appropriate treatments available to cure the illness. This principle (to avoid doing harm) is part of a cost-benefit relationship and also implies that the healthcare professional act in the best interest of the patient. At times, this may be in conflict in that to do no harm may result in judging treatment appropriateness (Rai, 2009).

Paternalism - Paternalism has a rather complex definition, but is essentially limiting the client's freedom of choice and action by "parental means" (e.g. the doctor or healthcare professional/system know best). It is interference with, or failure to respect the individual's rights, privacy, choice, or opportunities. It might, of course, be justified on the basis of a higher-good, but that would be a value judgment impaired upon the client by the caregiver without, in this case, proper qualifications since the issues in question are not necessarily medical in nature. Society naturally assumes that a parent will work toward the best outcome for the child, "my children come first," and in the medical world, as long as the deontological aspects do not become restrictive or disrespective, a degree of paternalism is expected (Veatch, 2000, 144-5).

Confidentiality - Confidentiality is now federally mandated to ensure the individual's right to privacy. Any medical or mental health professional is thus both legally and ethically obligated from revealing any client information obtained in a therapeutic situation with express permission (e.g. informed consent). In the field of mental health, however, there are some exceptions. For instance, if there is indication of harm to another individual, especially a child, confidentiality may be broken for safety reasons. The same holds true if the professional believes a client is at risk for harming themselves or another individual, or has made serious threats to that effect (Swenson, 1997). Often, a mental health professional may be asked to assist in legal or civil/criminal matters. In these cases, a waiver from the patient is either requested or subpoenaed from the issuing authority.

Conclusions - Because there are differences in types of euthanasia, so too there will be differences in the utility of the act. We can group topics (e.g. incurable disease, horrific pain and suffering, lack of quality of life), but each individual decision, based on classic utilitarianism, will judge the act based on the individual circumstances. This is indeed why the issue of utilitarianism and deontology is also inexorably tied with the right of the individual to make decisions based on their personal definition of life and/or quality of life. If there is no written documentation, then the considered opinions of those closest to the patient, based on a standard of utility, would need to suffice. Empirical research, for instance, on voluntary active euthanasia in Holland, suggests that the worries and comments about illegal mercy killing and situational abuse are really not too apparent. For utilitarianism to work, then, the decrease in suffering and increase in autonomy are enormous positive contributions to the right of the individual to decide on their own manner of death ((Hooker, 2000).

Discarding, for a moment, utilitarianism and deontology, and using the standard ethical rubrics for medicine, we find that when dealing with euthanasia:

The patient or representative has already made the decision; it is not up to the current healthcare staff to second guess that decision.

There is no conflict of justice in this case; all fair allocations in healthcare resources have been provided. If modern healthcare cannot help the patient, we must ask - is it hurting them?

The hospital has been truthful and loyal to the overall needs of the patient; if there was anything medically that could be done, it would have.

"At least do no harm" - there is an ethical dilemma here. "Harm" may be interpreted in numerous ways. If a brain is non-functioning, or a body will not breathe on its own, and any forceful methods may cause physical pain, then it may be kinder to allow a DNR or euthanasia request to stand..

The patient (aka the family) has been told the truth about the outcome, condition, and possibilities.

There is an obligation to use appropriate care; in this case, quality of care may interact with beneficence to provide a better ethical solution.

Modern medical technology has advanced further than societal wisdom, especially when confronting the issue of death. Thus, the nurses' role as an advocate is to facilitate, encourage or to enable patients to be involved in all aspects of their healthcare, and when unable to do so, act in their stead. This issue may blur, at times, when administering pharmaceuticals that may have potentially painful or negative side effects. However, while the nursing code of ethics echoes the Hippocratic Oath of "do no harm," the greater or long-term benefit to the patient may, at times, override brief discomfort in order to heal (Kamm). The subject of medical ethics remains complex; it is not just about what we can do medically, but what we should do. While the Hippocratic Oath indicates we should "do no harm," we must, as moral human beings decide if harming someone is limiting their possibilities and sentencing them to an existence of pain, suffering and torment - or drugged numbness and lack of awareness. Surely, history has taught us that as we grow in technological wisdom, so too should we not also grow in compassionate care? (McGrath and Forrester, 2006) Or, as some anthropologists believe, have we entered a state of philosophical irony in which part of the challenge of medicine is that now we can prolong life past where life should end? (Firth). Above all, if we as nurses have taken every measure possible to ensure advocacy for health care we must put our own belief systems aside and agree to carry out a legal order from a patient and, by doing so, fulfill our ethical responsibilities.

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