1 Background Information- Mr. J., an 89-year old male, smoked since he was 14.

He grew up in a coal mining town, dropped out of school and went to work to help the family through the Depression. He worked in the mines until most closed or phased out human workers for mechanization, and manifested Black Lung Disease (Coal workers pneumoconiosis) as well as emphysema. Three years ago, Mr. Js condition worsened, and he is now dealing with Stage IV lung carcinoma. Because of his age, and pulmonary history, no treatments to date have been effective, and he is not a candidate for any traditional therapy as he was also a heavy drinker and presents severe cirrhosis of the liver. His carcinoma has metastasized to his adrenal glands, osteosystem, and over the last few months, his brain. He is under tremendous stress and pain, and is depressed and despondent. His wife of 55 years died 2 years ago, and his children live several thousand miles away. As his says, most of his friends are pushing up daisies, and he is no longer able to live alone, even though his mind remain spry and cogent. He regularly coughs, typically presenting hemoptysis, is unable to walk even around his home without shortness of breath, rarely speaks because of the pain and hoarseness, must continually use supplemental oxygen, has difficulty swallowing and eating, no appetite, low blood sodium, and now bowel problems. His specialist does not believe he is a good candidate for new clinical trial medications because of his weakened condition and no chance of survival. At this point, he is on a symptom management protocol. Mr. J. has never been religious or even spiritual, indicating, that was the wifes department. Upon consultation with his lawyer and children via phone, Mr. J. decided to enter a local hospice program. His pain protocol is now so intense at times that he has requested that he be made comfortable and allowed to pass quietly. Unfortunately for Mr. J., his State does not allow for euthanasia. However, the mitigating factors are so drastic in this case, and his prognosis so

2 clear, that it is difficult for hospice staff to continue to watch his quality of life deteriorate and see him in such inexorable pain and suffering. Historical Paradigm- Euthanasia refers to the practice of intentionally ending a life in order to relieve pain, suffering, or intense discomfort. 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 persons right to choose their death (e.g. knowing they will become debilitated), and what constitutes a painless or happy death (Borry, Schotsmans and Dierckx, 2006). 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. Of course this was meant for the upper classes, in the hierarchy of the time, the lower and slave classes had no rights at all. 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).

3 Conflicts- 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 Terris 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 Courts 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).

4 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) (Overview of Arguments Against Euthanasia).

Ethical Agents- At the very center of the debate on euthanasia lies the core of individual and societal ethics. Ethics is a way humans try to explain the way morals fit into culture within a specific timeframe. It is non-judgmental in that it deals with understanding the dilemmas rather than judging. Often ethics tests the boundaries of generational thought becoming more acceptable to future generations than the present based on the evolution of society. The principles of ethics that have particular relevance to our subject center on the juxtaposition between utilitarianism and deontology. 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 State (Athens, for example); and throughout history generals and heads of state have had to balance out the ends versus the means of attainment. 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

5 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). Utilitarianism holds that the most ethical thing one can do is any action that will maximize the happiness within an organization or society. 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 Bentham. 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

6 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) Alternative Solutions and Potential Conflicts - 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 them based on a standard of utility would need to suffice. Empirical research, for instance, 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). Principles/Theories Applied- 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,

7 and in turn, the relationship between the nurse and the person in care. However, a combination of the literature and personal observation shows that modern nursing tends to support the means as being ethical (deontology) and support for the client (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 ones own actions, and the decisions one makes must be respected by others. Justice Justice in medical ethics requires that we provide equal healthcare to all regardless of our resources and regardless of the persons class or economic status. Fidelity Requires that there be a truthful and reciprocal relationship between healthcare provider and patient and vice versa. 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 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.

8 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. Paternalism Paternalism has a rather complex definition, but is essentially limiting the clients freedom of choice and action by parental means (e.g. the doctor or healthcare professional/system knows best). It is interference with, or failure to respect the individuals 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. Confidentiality - Confidentiality is now federally mandated to ensure the individuals 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 (Benhamin & Curtis, 2010). Solution- From an ethical position, the nurse is torn. Legally and base on doctrines from her own profession, she cannot assist or intercede in a case like this. Morally, she cannot allow or bear suffering. In general, while there is continuum of end-of-life choices that the medical profession describes, the nurse should not participate in assisted suicide. Such an act is in violation of the Code for Nurses with Imperative Statements and the ethical traditions of the profession (American Nurses Association Board of Directors, 1994). The legal statues vary from state to state,

9 and with the exception of Oregon, Washington and Montana, medical professionals may not assist in suicide or withhold care to keep a patient alive (Dignity in Dying, 2011). Describe Action There is only one possible action that can be taken- legally. The nurse cannot put themselves, their license, or their institution in legal rusk. However, all is not lost for Mr. J. There are devices that load directly into a persons IV or vein, usually with a setting to prevent accidental overdose. Because of the tolerance level for such pain, Mr. Js cut off has been disabled, though. In order for him to be comfortable, he is instructed on the use of the device and will therefore have additional control over how much medication he is able to take, simply to be able to sleep at night. This is all the profession can do at the moment, be kind, be empathetic, and make the patient as comfortable as possible under the confines of the law; then work from the inside out to develop and change legislation as necessary.

10 Works Cited Information for Research on Euthanasia. (2009, December). Retrieved December 2011, from Euthanasia.com: http://www.euthanasia.com/index.html Overview of Arguments Against Euthanasia. (2010, January). Retrieved December 2011, from BBC Ethics Guide: http://www.bbc.co.uk/ethics/euthanasia/against/against_1.shtml Dignity in Dying. (2011, January). Retrieved December 2011, from Dignityindying.uk: http://www.dignityindying.org.uk/ American Nurses Association Board of Directors. (1994, December 8). Assisted Suicide. Retrieved December 2011, from Nursing World: http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-andResolutions/ANAPositionStatements/Position-StatementsAlphabetically/prtetsuic14456.html Benhamin, M., & Curtis, J. (2010). Ethics in Nursing - Cases, Principles, reasoning. New York: Oxford University Press. Borry, Schotsmans and Dierckx. (2006). Empirical Research in Bioethical Journals: A Quantitative Analysis. Journal of Medical Ethics, 32(4), 240-45. Goodman, K. (Ed.). (2009). The Case of Terri Schiavo: Ethics, Politics, and Death in the 21st Century. Oxford: Oxford University Press. Haydn, P. (2001). The Philosophy of Human Rights. New York: Paragon Press. Hooker, B. (2000). Rule Utilitiarianism and Euthanasia. In Hooker, Mason, & Miller (Eds.), Morality - Rules and Consequences (pp. 22-31). Edinburgh: owman and Littlefield.

11 Kamm, F. (2007). Intricate Ethics: Rights, responsibilities, and Permissible Harm. Oxford: Oxford Univerisyt Press. Robinson and Groves. (2003). The Classic Utilitarians - Bentham and Mill. New York: Hackett Publications. Sandhyarani, N. (2009, January). History of Euthanasia. Retrieved December 2011, from Buzzle.Com - Intelligent Life on the Web: http://www.buzzle.com/articles/history-ofeuthanasia.html Troyer, J. (2003). The Classical Utilitarians - Bentham and Mill. New York: Hackett Publications. Tschudin, V. (2003). Ethics in Nursing. Stoneham, MA: Butterworth.