PASSIVE EUTHANASIA (LIMITATION OF THERAPEUTIC EFFORT) - MEDICINE - 2025

The passive euthanasia or limitation on of the therapeutic effort (LTE) is a medical procedure that involves removing or not to start treatment, both pharmacological and instrumental, which would not be a benefit to the patient, pain or suffering.

Today it is considered a legitimate medical practice, synonymous with good practice, due to a paradigm shift in medicine in which more importance is given to the general condition and quality of life of the patient than to their mere survival (Borsellino, 2015; Baena, 2015).

LET, therefore, should not be confused with euthanasia or assisted suicide, illegal practices in most countries of the world.

The limitation of therapeutic effort: definition

Thanks to technological advances and knowledge in medical science, today there are many tools that allow to keep a patient alive beyond what nature would have foreseen.

There is a wide spectrum of treatments and interventions that prolong life, but do not ensure recovery: artificial respiration, hydration or feeding, dialysis, cardiac resuscitation, or chemotherapy, to name a few (Borsellino, 2015).

However, the fact of survival is not a guarantee of quality of life or well-being, aspects that current medical science emphasizes much more than half a century ago.

Thus, according to Martínez (2010), doctors should examine and treat their patients in such a way that, at least, the effects of their actions always lead to an improvement in their quality of life.

This is why LET does not imply in any case a limitation of care, since ensuring the well-being of the patient is as important as previous attempts to cure it (Winter and Cohen, 1999).

Therefore, situations are common in which life-prolonging treatment may not be the best for a patient with no hope of cure (Doyal and Doyal, 2001). It is at this time that the medical professional and the patient (or their family members) can decide not to start or withdraw such treatment.

At this point, it is important to highlight that all patients of legal age and in full consciousness (or their family members) have the right to refuse any medical procedure, and it is never a decision made unilaterally by medical personnel (NHS Choices, 2017).

As mentioned before, LET has become a standard and widely accepted practice in recent times (Brieva, Cooray & Prashanth, 2009; Hernando, 2007).

Difference between LET and euthanasia

Euthanasia is the action, by a medical professional, of intentionally ending the life of another person, usually a terminally ill patient, with the aim of saving pain and suffering.

The name "euthanasia" comes from ancient Greek and means "good death." Despite being similar to assisted suicide, it should not be confused with it. Assisted suicide implies that the physician provides the means for suicide, which is subsequently carried out by the same patient.

However, in the case of euthanasia, it is the doctor who performs all the steps (Harris, Richard and Khanna, 2005). To date, both procedures are controversial and illegal in most parts of the world, with some form of them only allowed in less than a dozen countries (Wikipedia, 2018).

However, in the case of TBI, the death of the patient is not the direct consequence of the physician's actions and, as mentioned in previous paragraphs, it is a widely accepted measure.

For example, a study carried out among Spanish medical professionals revealed that the vast majority of them (98%) agree with this procedure (González Castro et al., 2016).

Ethical dilemma?

A few decades ago, before it became the common practice that it is today, there was a debate within medical ethics and bioethics about LET. This debate focused on whether there was any moral difference between LET or "letting die" and euthanasia or "killing."

Some authors such as Rachels (1975) argued that such a moral difference did not exist, and that in some cases euthanasia could be morally superior since it avoids the suffering of the patient to a greater extent.

Others, such as Cartwright (1996), argued that in the case of "killing" there was an agent who initiated the causal sequence, while in the case of "letting die" the agent was responsible for the lethal causal sequence.

Present

At present, however, this debate is considered outdated and the only controversy lies in those cases in which the patient cannot directly express his consent, for example because he is in a vegetative state or because he is a young child.

In these situations, it is usually the family that has the last word, based on what the patient may have said at a previous time.

Likewise, it is also possible that the patient had signed a document declaring his will when he was in a conscious state, which is above the will of his relatives (NHS Choices, 2017).

Example

An example of this controversy can be found in the media case of Alfie Evans, a British boy of almost two years of age who was born with a degenerative neurological disease.

In hospital since he was seven months old, he had no options for recovery, and the doctors claimed that the best, and most humane, course of action was to let him die.

Instead, his parents, supported by the Italian and Polish governments and the Pope, believed that Alfie did have a chance of survival, and refused to consent.

Finally, the British Court of Appeal decreed the withdrawal of the treatment that kept Alfie alive, as well as the prohibition of his parents from seeking new alternative treatments.

According to the court, continuing the treatment would have only prolonged the child's suffering, which went against his own interests (Pérez-Peña, 2018).

References

1. Baena Álvarez, C. (2015). Limitation of therapeutic effort: when less is more. Medical Colombia 46 (1) pp: 1-2. Available at ncbi.nlm.nih.gov.
2. Borsellino, P. (2015). Limitation of the therapeutical effort: ethical and legal justification for withholding and / or withdrawing life sustaining treatments. Multisdisciplinary Respiratory Medicine 10 (1) p. 5. DOI: 10.1186 / s40248-015-0001-8
3. Brieva, JL, Cooray, P. and Rowley, M. (2009). Withholding and Witdrawal of Life-Sustaining Therapies in Intensive Care: An Australian Experience. Critical Care and Resuscitation 11 (4) pp: 266-268. Available at search.informit.com.au.
4. Cartwright, Will. (nineteen ninety six). Killing and letting die: a defensible distinction. British Medical Bulletin, 52 (2), pp: 354-361. Available at academic.oup.com.
5. Doyal L. and Doyal, L. (2001). Why active euthanasia and pshysician assisted suicide should be legalized. British Medical Journal 323 (7321) pp: 1079-1080. Available at ncbi.nlm.nih.gov.
6. González Castro, A., Azcune, O., Peñascos, Y., Rodríguez, JC, Domínguez, MJ and Rojas, R. (2016). Opinion of professionals in an intensive care unit on the limitations of therapeutic effort. Healthcare Quality Magazine: organ of the Spanish Society for Healthcare Quality 31 (5) pp: 262-266. DOI: 10.1016 / j.cali.2015.12.007.
7. Harris, D., Richard, B. and Khanna, P. (2006). Assited dying: the ongoing debate. Postgraduate Medical Journal, 82 (970), pp: 479-482. DOI: 10.1136 / pgmj.2006.047530.
8. Hernando, P., Diestre, G. and Baigorri, F. (2007). Limitation of therapeutic effort: a question for professionals or for patients as well? Annals of the Navarra Health System 30 (3) pp: 129-135. DOI: 10.23938 / ASSN.0207.
9. Martínez González, C. (2010). Limitation of the diagnostic effort in paediatrics. Journal of Medical Ethics 36 (11) pp: 648-651. DOI: dx.doi.org/10.1136/jme.2010.036822.
10. NHS Choices. (2017, January 11). Do I have the right to refuse treatment? Available at nhs.uk.
11. Pérez-Peña, R. (2018, April 26). Fight Over Alfie Evans, a Brain-Damaged Baby, Divides UK The New York Times. Available at nytimes.com.
12. Rachels, J. (1975). Active and Passive Euthanasia. The New England Journal of Medicine, 292, pp. 78-80. Available at sites.ualberta.ca.
13. Wikipedia (2018, May 29). Legality of euthanasia. Available at en.wikipedia.org.
14. Winter, B and Cohen, S. (1999). Withdrawal of treatment. British Medical Journal 319 p. 306. DOI: doi.org.