RESEARCH METHODOLOGY AND BIOSTATISTICS : UNIT-IV: Medical fatality i

Case fatality rate, also called case fatality risk or case fatality ratio, in epidemiology, the proportion of people who die from a specified disease among all individuals diagnosed with the disease over a certain period of time. 

1. 1
Fatality

2. 2
What do you understand as fatality?
a.Anoccurrenceofdeathbyaccident,inwar,orfrom
disease.

3. 3
What is meant by fatality rate?
Casefatalityrate,alsocalledcasefatalityriskor
casefatalityratio,inepidemiology,theproportionof
peoplewhodiefromaspecifieddiseaseamongall
individualsdiagnosedwiththediseaseoveracertainperiod
oftime.

4. 4
QUIZ
1.Anoccurrenceof______byaccident,inwar,orfrom
disease.
a.Birth
b.Life
c.Invention
D.Death

5. 5
Mortal Responsibilities: Bioethics and Medical -
Assisted Dying

6. 6
INTRODUCTION
1.Acultureofdyingcharacterizedbyend-of-lifecare
providedbystrangersininstitutionalsettingsand
diminishedpersonalcontrolofthedyingprocesshasbeen
acatalystfortheincreasingprevalenceoflegalized
physician-assisteddyingintheUnitedStatesand
medically-assisteddyinginCanada.

7. 7
2.Themorallogicoftherighttodiethatsupports
patientrefusalsoflife-extendingmedicaltreatments
hasbeenexpandedbysomescholarlyargumentsto
provideethicallegitimationforhasteningpatient
deathseitherthroughphysician-prescribedmedications
ordirectphysicianadministration ofalethal
medication.

8. 8
3.Theconceptofmedical-assisteddyingincreasestherole
andpowerofphysiciansinendinglifeandallowspatients
whoarenotterminallyill,orwhohavelostdecision-
makingcapacity,orwhoaresufferingfromairremediable
medicalconditiontohaveaccesstomedicalproceduresto
hastendeath.

9. 9
4.Thisextendedmorallogiccanbecounteredbyethical
objectionsregardingtheintegrityofthepatient-physician
relationshipandlastresortsinendinglife,professional
concernsaboutmedicalizationandadiminishedidentityof
medicine as a healing profession, and social
responsibilitiestoprovideequalaccesstobasichealth
careandtohospicecare.

10. 10
Dying Well, Dying Badly

11. 11
a.TheDanishphilosopherSorenKierkegaardobservedthat“dyingwell
isthehighestwisdomoflife”.
b.However,asmanyscholarsandphysicianshaveobserved,American
cultureiscurrentlypermeatedwitha“plagueofbaddying”,which
ischaracterizedbydyinginaninstitutionalizedsetting,under
thedepersonalizedcareofstrangers,monitoredbytechnologies,
andsubstantiallyreducedpersonalandfamilialcontroloverthe
dyingprocess.

12. 12
c.Oneincreasinglyprevalentresponsetothiscultureofbad
dyingwithinbiomedicineandinhealthcarepolicyisthe
legalizationofmethodsoverseenbyphysicianstohastenthe
deathsofpatientswithincurableterminalillness.
d.TherearenowtenUSjurisdictionsthatpermitphysician-
assisteddeath,thatis,aprocessinwhichphysiciansmay
writeaprescriptionthatpatientsmaychoosetoself-
administertoendtheirlife

13. 13
–Oregon(1994),Washington(2008),Montana(2008),Vermont
(2013),California(2015),Colorado(2016),theDistrictof
Columbia(2017),Hawai’i(2018),NewJersey(2019),andMaine
(2019).

14. 14
QUIZ
2.The________philosopher Soren Kierkegaard
observedthat“dyingwellisthehighestwisdomof
life”.
a.Indian
b.American
C.Danish
d.Canada

15. e.Physician-assisteddeathisnowalegalizedoptionfor
terminallyillpatientsinstatesthatcomprisenearly25
percentoftheUSpopulation.
f.Inthisdiscussion,Iwishtosituatetheongoing
legalizationofphysician-assisteddeathwithinaconceptual
narrativeofthe“righttodie”sincethe1970s,andthenmake
anethicalargumentagainstsuchlegalizationanditsexpanded
scopeintoarightto“medical-assisteddying.”
15

16. The Moral Logic of the Right to Die
16

17. 1.Likemanyprogressivistsocialmovementsthatextol
exemplars,advocacyoflegalizedphysician-assisteddeath
haselevatedthedyingnarrativeofarelatableand
identifiableindividual,BrittanyMaynard,foritspublic
faceandprofileincourage.
2.Ms.Maynard,arecently-marriedwomaninherlate20s,was
diagnosedinJanuary2014withanadvancedformofbrain
cancer
17

18. 18
thatledherphysicianstoconcludeshehadaprognosisof
approximatelysixmonthsofremaininglife.
3.Ms.Maynardsoughttoretaincontrolandpersonaldignity
inherdyingprocessandoptedtoreceiveaphysician-
prescribedmedicationtohastenherdeath.
4.ThisprocesswascomplicatedsinceMs.Maynardandher
spouse,DanDiaz,livedinCalifornia,astatethatatthe
timedidnotpermitphysician-assisteddeath.

19. 19
QUIZ
3.Physician-assisteddeathisnowa____________option
forterminallyillpatientsinstatesthatcomprise
nearly25percentoftheUSpopulation.
a.Illegal
B.Legalized
c.Banned
d.Noneofabove

20. 5.Thecouplere-locatedtoOregon,astatethathadpassed
thenation’sfirst“deathwithdignity”statutein1994.
6.PriortoherdeathfromthemedicationinNovember2014,
Ms.Maynardandherspousebecamenationally-knownadvocates
forlegalizationofphysician-assisteddeathinallUS
states.
20

21. 7.Thecompellingpersonalstoryhadadirectimpacton
publicpolicy:Californiapassedan“EndofLifeOption
Act”thefollowingyearthatpermittedterminallyill
patientstoreceivealife-endingmedicationfromtheir
physician,andpassageofsimilarlawsmodeledonthe
originalOregonstatutesubsequentlyfollowedinColorado,
Hawai’i,NewJersey,andMaine.
21

22. 8.Theincreasingprevalenceoflegalizedphysician-assisted
deathreflectsthemorallogicoftheconceptof“therightto
die,”whichwasintroducedinpublicandprofessional
discourseandinprecedent-settingcourtcasesaboutstopping
ventilatorsupportinthe1970sandcessationofnutritionand
hydrationthroughfeedingtubesinthe1980sand1990s.
22

23. 9.Themorallogicoftherighttodieaffirmsthatpatients
haveafundamentalinterestin
a.bodilyintegrity,
b.freedomfrominvasivemedicalinterventionsthatarelikely
tobefutileinprolonginglifeorrestoringaqualityof
life,and
c.self-determinationaboutdecisionstoendlifeaccordingto
theirvalues.
23

24. 10.Theseinterestswererecognizedinfederalandstatelaws
authorizingpatientstocomposeadvancedirectivesrequesting
treatmentoritsdiscontinuation.
24

25. 25
QUIZ
4.Theincreasingprevalenceoflegalizedphysician-assisted
deathreflectsthemorallogicoftheconceptof“__________,”
whichwasintroducedinpublicandprofessionaldiscourseand
inprecedent-settingcourtcasesaboutstoppingventilator
supportinthe1970sandcessationofnutritionandhydration
throughfeedingtubesinthe1980sand1990s.
A.Therighttodie c.therighttolive
b.Therighttoact d.therighttofreedom

26. 26
11.Thescopeoftherighttodieunderadvancedirective
legislationwasprimarilylimitedtorightstorefuseor
withdrawburdensomemedicalinterventions.
12.ThepassageoftheOregonDeathwithDignityActin1994
permittingterminallyillpatientstorequestalife-ending
medicationfromtheirphysicianrepresentedanewprofessional,
ethical,andlegalthreshold.

27. 27
13.Philosophicalandpoliticaladvocacyoflegalization
reliedonthecoremorallogicoftherighttodiewhile
claimingthatsuchlogicwarrantedexpandingthescopeofthe
righttodiefromrefusingorwithdrawingburdensomelife-pro
longingmedicalinterventionstoaterminallyillpatient’s
righttorequestassistancefromaphysician,effectuated
throughaprescribedmedication,thatwouldhastentheir
deathina“humaneanddignifiedmanner”.

28. 28
14.Suchphilosophicandpoliticalargumentsextendingthe
scopeoftherighttodiewerenotwithoutcontroversy.
15.Criticsarguedthatthecorepatientinterestsprotectedby
therighttorefusemedicaltreatmentconstituteda“negative”
righttonon-interventionandnon-interferenceindying.
16.Mostofourcivic,political,andhumanrights,afterall,
makeaclaimagainstothersofnon-interventioninpersonal
liberty.

29. 29
17.Anegativerighttodyingcouldnot,however,
legitimize apatient claimtophysician-prescribed
medicationtoendlife,whichreflectsthemorallogicofa
“positive”righttoassistanceincarryingoutone’s
desiredactions.

30. 30
QUIZ
5.Criticsarguedthatthecorepatientinterests
protectedbytherighttorefusemedicaltreatment
constituteda“_________”righttonon-intervention
andnon-interferenceindying.
a.Positive
b.Optimistic
c.Constructive
D.Negative

31. 31
QUIZ
6.Anegativerighttodyingcouldnot,however,
legitimizeapatientclaimtophysician-prescribed
medicationtoendlife,whichreflectsthemorallogicof
a“__________”righttoassistanceincarryingoutone’s
desiredactions.
a.Constructive
b.Optimistic
C.Positive
d.Negative

32. 32
18.Criticsalsoclaimedthatphysicianassistanceina
patient’sdeathcompromisedaprofessional’scommitmentto
healingandcompassion.
18a.AsarguedbyJusticeNeilGorsuchpriortohis
appointmenttotheUSSupremeCourt,constructingtherightto
dieasapositiverightcontainedaninexorablemorallogic
thatwouldinevitablypermitnotonlylegalizedphysician-
assisteddeathbutalsolegalizedphysician-administered
euthanasia.

33. 33
19.AlthougheveryUSjurisdictionthathaslegalizedphysician
prescribedmedicationstohastenapatient’sdeathhasalso
retainedprohibitionsofphysicianeuthanasia,thisseemedto
criticsdefensibleonlyasaprudentialratherthanprincipled
consideration.
20.Legalizationproponents,meanwhile,havelongexpressed
concernthatphysician-assisteddyinglawsmodeledafterthe
Oregonstatuteriskexclusionarydiscriminationtowardssome
terminallyillpatients.

34. 34
21.Statutoryprovisionsthatrequireapatienttoself-
administerthelife-endingmedicationandtoretaindecision-
makingcapabilitythroughouttheirdyingprocessimpose
difficult,ifnotexclusionary,burdensforcertainpatients,
suchaspersonswithlate-stageALS(Amyotrophiclateral
sclerosis) wholackthephysical mobility forself-
administrationorpersonswithlate-stagedementiawhomaylose
theirdecision-makingcapacityinthecourseoftheirillness.

35. 35
22.Legalizationproponentshaverecentlyinvokedafurther
policyprecedentembeddedinthemorallogicoftherightto
dieandclaimedthatpatientsseekingphysicianassistancein
dyingshouldnotbeheldtoamoredemandingstandardfor
expressingandeffectuatingtheirwishesthanpersonswho
utilizeadvancedirectivestoexerciserightstorefuseor
withdrawlife-sustaininginterventions.

36. 36
23.Theappropriationofrequirementsfordecision-making
capacityfromadvanceddirectivelegislationintopatient
deliberationonrequestingphysicianassistanceindying
wouldmeanproxiescouldmakesurrogatedecisionsforthe
patientbasedonthepatient’svaluesintheeventofloss
ofdecision-makingcapacity.

37. 37
24.Theserestrictionsincurrentphysician-assisteddeath
statuteshavepromptedethicalandprofessionalargumentsand
patientadvocacytoextendthescopeoftherighttodiestill
further.
25.Thesearguments,presentedformallyata2018workshop
sponsoredbytheNationalAcademyofMedicine,maintainthatthe
righttodieshouldencompass(1)physician-administered
medicationsforterminallyillpersons,someofwhommaynolonger
have(2)decision-makingcapacity.

38. 38
QUIZ
7.Theserestrictionsincurrentphysician-assisteddeath
statuteshaveprompted________andprofessionalargumentsand
patientadvocacytoextendthescopeoftherighttodie
stillfurther.
a.Unethical
B.Ethical
c.Immoral
d.Atrocious

39. 39
26.Moreover,advocatescontendthatcertainmedicalconditions
afflictingchronicallyillpersonscanimposeanexperienceof
unbearablepainandsufferingforwhicheventhebestof
palliativecaremeasuresareinadequateforthepatient.
27.Consequently, accesstoeitherself-administered or
physician-administeredmedicationstoendlifeshouldalsobe
availabletonon-terminallyillpersonswithnoterminal
diagnosisbutwhoareexperiencingagrievousandirremediable
medicalcondition.

40. 40
28.Thatis,themorallogicoftherighttodiehasevolved
frompatientdecisionstorefuseorwithdrawburdensomeor
futiletreatmenttopatientdecisionstorequestphysician
prescribedmedicationstohastendeathtopatientdecisionsto
requestdirectphysicianadministrationofalethalagentwhen
theunderlyingindicationisnotterminalillnessbutnon-
relievablepainandsuffering.

41. 41
29.Thislatterethicalterrain,whichhistoricallyhasbeen
designatedbytheconcept“euthanasia,”hasbeenre-
conceptualizedasapatientrighttomedically-assisted
dyingtoavoidthehistoricalassociationsofinvoluntary
medicalkillingattachedto“euthanasia.”

42. 42
30.Theconceptofmedicalaidindyingwasintroducedin
publicdiscourseontheColoradoEndofLifeOptionsAct
passedinfall2016thatpermittedpatientstoself-
administeramedicationtoendlifebutretainedthe
conventionalprohibitionsonphysician-administeredlife-
endingmedications.

43. 43
31.However,legalization advocatesandbioethics
scholarshavefoundtheinexorablemorallogicofthe
righttodieexemplifiedinlegislationapprovedbythe
CanadianParliamentinJune2016.

44. 44
QUIZ
8.Theconceptofmedicalaidindyingwasintroducedin
publicdiscourseontheColoradoEndofLifeOptionsAct
passedinfall________thatpermittedpatientstoself-
administeramedicationtoendlifebutretainedthe
conventionalprohibitionsonphysician-administeredlife-
endingmedications.
A.2016
b.2019
c.2020
d.2012

45. 45
32.TheCanadianlawpermitsboth“clinician-administered
medicalassistanceindying”inwhichaphysicianornurse
practitioner“directlyadministersasubstancethatcauses
death”and“self-administeredmedicalassistanceindying,”in
whichaphysicianornursepractitioner “providesor
prescribesadrugthattheeligiblepersontakesthemselves,
inordertobringabouttheirowndeath.”

46. 46
33.ThestipulationinUSphysician-assisteddeathstatutes
thatapatientmustbediagnosedwithaterminalillnessis
notarequirementforaccesstomedically-assisteddyingin
Canada;rather,thetriggeringconditionisdesignatedasa
“grievousandirremediablemedicalcondition,”aconstruct
referringtoa“seriousillness,disease,ordisability”

47. 47
thathasadvancedtoastagewheretheconditionis(a)no
longerreversiblebymedicalinterventionand(b)causesthe
patientto“experienceunbearablephysicalormentalsuffering
thatcannotberelievedunderconditionsthat[thepatient]
consider[s]acceptable”.
34.Withinthisconstruct,(c)aperson’sdeathwillhave
become“reasonablyforeseeable,”

48. 48
butthisdoesnotpresupposeanyspecifiedminimaltemporal
durationtotheirlifeexpectancy.

49. 49
QUIZ
9.The________permitsboth“clinician-administeredmedical
assistanceindying”inwhichaphysicianornurse
practitioner“directlyadministersasubstancethatcauses
death”and“self-administeredmedicalassistanceindying,”
inwhichaphysicianornursepractitioner“providesor
prescribesadrugthattheeligiblepersontakesthemselves,
inordertobringabouttheirowndeath.”
a.Americanlaw c.Australianlaw
b.Indianlaw D.Canadianlaw

50. 50
35.TheCanadianlegislationbuildsonthecentral
principlesofpatientself-determination,personalbodily
integrity,andfreedomfromunwantedmedicalinterventions
inthemorallogicoftherighttodie,butextendsthese
principlesbysupplementingpersonalautonomywithan
appealtothehistoricalprofessionalimperativeto
address“unbearable”painandsuffering.

51. 51
36.Scholarshaveadvocatedappropriatingfeaturesofthe
Canadianlegislationtoaddresstheperceivedinadequacies
ofcurrentphysician-assisteddeathstatutesintheUS.

52. 52
37.Thisoverviewoftheethical,professional,andlegal
expansionoftherighttodieprovidescontextformy
subsequentnormativeargument.
38.Philosophicalandprofessionaladvocacyofthisexpanded
righttodieengagesintwoassumptionsofethical
equivalence:(1)Physician-assisteddeathisthemoral
equivalentofwithdrawingorrefusingfutilemedical
treatments,and(2)Medical-assisteddyingisthemoral
equivalentofphysician-assisteddeath.

53. 53
39.Itfollowsfromtheseclaimsthatthereisnomoral
differencebetweenpatientrequestsformedical-assisted
dyingadministeredbyaclinician,thatis,physician-
administeredeuthanasia,andpatientrequeststowithdrawor
refusefutilelife-prolongingmedicaltreatments.
40.Irejecttheseclaimsofethicalequivalence.

54. 54
41.Icontendthereisamorallinebetweenrightstorefuse
treatmentandrightstophysician-assisteddeathandthat
legalizingphysician-assisteddeathdoesnotresolvethe
ethicalquestions.
42.Ialsocontendthatmedically-assisteddyinginthe
UnitedStatesisprematureandethicallyobjectionable,and
riskscompromisingprofessionalintegrityandsoundpublic
policyregardingend-of-lifecare.

55. 55
QUIZ
10.Icontendthereisamorallinebetweenrightsto
refusetreatmentandrightstophysician-assisteddeathand
thatlegalizingphysician-assisteddeathdoesnotresolve
theethicalquestions.
a.Immoral
b.Bad
C. Moral
d. Dishonourable

56. 56
An Argument Against Legalization: A
Premature Policy

57. 57
a.Whilethefrequencyoflegalizingphysician-prescribed
medicationstohastenthedeathofaterminallyillpatient
hasincreasedinthepastfiveyears,themajorityofUS
stateshavefoundthatadvancedirectives,meaningful
professionalandfamilialconversations,andaffirmingthe
negativerighttorefusemedicaltreatmentgenuinely
advancespatientinterestsinend-of-lifecare.

58. 58
b.Thismorelimitedscopeoftherighttodieallows
choicesaboutend-of-lifetreatmentrefusalstobethe
provinceofthepatient(andfamily)andphysician
relationshipwithoutstatemicro-management.

59. 59
c.End-of-lifecarecanofcoursebeimproved:numerous
recentprofessionalarticlesandpublic-orientedbooksby
physicianauthorsinend-of-lifecaresuggeststhe“plague
ofbaddying”hasverymuchcapturedbothprofessionaland
medicalattentionandthefocusofthepublic.

60. 60
d.However,issuesofdepersonalizedcare,mismanaged
medical technologies, institutionalized dying, and
diminishedpatientandfamilialcontrolofthedyingprocess
canbeaddressedthroughadvocacyofongoingreformsinthe
patient-physicianrelationship(conversationsaboutpatient
preferences),institutionalsettings(encouragingadvance
directives),andthesocialstructuresofcare(providing
sufficientpalliativecareandpaincontrol).

61. 61
e.Itisethicallyprematuretoconcludethattheprimary
waytoremedythemedicalizedcultureofbaddyingis
allowingphysicianstobedirectlyinvolvedinendingthe
lifeoftheirpatient.
f.Advocacyoflegalizedmedicalassistanceindyingisalso
prematurebecauseendoflifecareintheUShasnot
utilizedsufficientlytheoptionsthatallowpatientsto
experiencecontrolandqualityoflifeasdeathdrawsnear.

62. 62
QUIZ
11.__________carecanofcoursebeimproved:numerous
recentprofessionalarticlesandpublic-orientedbooksby
physicianauthorsinend-of-lifecaresuggeststhe“plague
ofbaddying”hasverymuchcapturedbothprofessionaland
medicalattentionandthefocusofthepublic.
a.Personal c.Oldagecare
b.Child D.End-of-life

63. 63
g.Thephilosophyandpracticeofhospicecarehistorically
soughttoprovideamiddlepathinend-of-lifecarebetween
vitalisticprolongationoflifebymedicaltechnologiesand
physicianinterventiontohastenapatient’sdeath,tothe
endsofrespectingthedignityofthepatientasaperson,
minimizingpain,providingpatientcontroloverdying,and
viewingdyingasanopportunityforcultivatingmeaningful
relationshipclosureandpersonalmeaning.

64. 64
h.Thelegaloptionofphysician-assisteddeathisa
relativelyrareoccurrenceinpartbecauseofthecontinued
commitmentstoholisticcaredeliveredbyhospiceprograms.
However,hospicecareremainsanunder-utilizedoptioninthe
cultureofdying,withthenumberofpersonscoveredby
Medicareandreceivinghospicecareatthetimeofdeath
rangingbystatefrom23to58percent.Referralsoraccessto
hospicecarestilltendtooccurlateinthedyingprocess.

65. 65
I.Patientswhoreceivehospicecareservicesforaweekor
lesscomprise27.9percentofthehospicepopulation.
J.Hospicehasbeenportrayedbyprominentphysiciansand
writersinend-of-lifecareastheartesmoriandior“artof
dying”foroureraofhigh-technology,depersonalized,and
protracteddying.

66. 66
K.Bioethicalandprofessionalcultureshaveanethical
responsibilitytoworktowardsuniversalaccesstohospice
carewhenhospicecanbemosteffectiveinmeetingboth
patientneedsanditshistoricalmoralmissionbefore
determiningthatmedically-assisteddyingistheremedyfor
theplagueofbaddying.

67. 67
QUIZ
12.________careremainsanunder-utilizedoptionin
thecultureofdying,withthenumberofpersons
coveredbyMedicareandreceivinghospicecareatthe
timeofdeathrangingbystatefrom23to58percent.
a.Adult C.Hospice
b.Infant d.Animal

68. 68
Ethical Objections

69. 69
1.Therearecompelling philosophical considerations
supportinglegalizationofphysician-assisteddeathand
medical-assisteddying:Atabroadconceptuallevel,who
wouldreallybeopposedtoadignifieddeath?However,
legalizationargumentsappealingentirelytopatientself-
determinationmistakenlypresumethatsuchactionsinvolvea
“private”patientchoiceandaretherebyimmunefrommoral
assessment.

70. 70
2.Apatientwhorequestsmedicalaidindyingrequires
theassistanceofaprofessional,aqualifiedphysicianor
nursepractitioner,thatis,apersonwhoispartofa
moralprofessioninwhomsocietyhasreposedtrustthat
theprofession’smemberswillexercisetheirknowledge,
skills,andproficienciesinthehealingartsforthe
benefitofbothpatientandsociety.

71. 71
3.Physician-assisteddyingandmedical-assisteddyingare
necessarily “public” actions thatrequire forums for
professionalandpublicaccountability.
4.Thefocusoflegalizationadvocatesonpatientrightsand
interestshasgeneratedmoralmyopiaregardingthepresenceof
otherstakeholdersincludingvariousintermediatecommunities
suchasfamilies,thehealingprofessions,hospicecare,and
spiritualcareadvisors,ascontributors toend-of-life
caregiving

72. 72
5.Themorallogicofendinghumanlifeinanycontext
requiresthatanysuchactionsbeundertakenasalast
resort.Therearealternativeoptionsinend-of-lifecare
thatcanbestowondyingpersonsameasureofcontrol
overthedyingprocess,confervaluetodyingandopen
pathstomeaningshortofaperceivednecessitytohasten
deathbymedicalmeans.

73. 73
6.Evenphysicianadvocatesoflegalizedphysician-assisted
dyinghaveidentifiedseveral“lastresort”optionsfor
assuringanexperienceofdyingwellforterminallyill
persons,includingexercisingthesubstantiallegalrights
personsandtheirproxiesalreadyhaveinallstatestorefuse
lifeextendingmedicaltreatmentsthroughadvancedirectives;
thegoldstandardofhospicecareandpalliativemedicine;

74. 74
thedoubleeffectpracticeofprovidingsufficientsedation
toalleviatepainevenifanunintendedoutcomeisa
hasteneddeath;and,voluntarilystoppingeatingand
drinking.

75. 75
QUIZ
13.Physician-assisteddyingandmedical-assisteddyingare
necessarily“_______”actionsthatrequireforumsfor
professionalandpublicaccountability.
a.Personal c.Personnel
B.Public d.Official

76. 76
7.Itisethicallyincumbenttoretainthesemethodsas
resortsfordyingoflastrecourseratherthanoffer
physician-ormedically-assisteddeathaseithera“first
resort”orasoneend-of-lifeoptionamongmanymorally
equivalentoptions.Theseconventionallastresortsoffer
respect,control,relationalclosure,andqualityofdying
forthevastmajorityofdyingpersons.

77. 77
8.EveninOregon,thestatewiththemostextensive
longitudinalexperienceofutilizationofphysician-
assisteddeathbyterminallyillpatients,studies
indicatethatlessthan0.2percentofalldeaths
occurthroughrecoursetothemedicalprocedures
availablebythestate’sDeathwithDignityAct.

78. 78
9.Thepurportedethicalequivalenceoftreatmentrefusals
withphysician-assisteddeathandmedical-assisteddyingalso
invitescriticalscrutiny.
10.Thisdoublemoralequivalencepresumesthattheonly
ethicallyrelevantconsiderationisinformedpatientchoice,
butitneglectstosituatesuchchoiceswithinethically
importantmattersofcausation,humanagency,intention,and
responsibilityforoutcomes.

79. 79
11.Thenegativerighttorefuseorwithdrawmedical
treatmentinvolvesanunderstandingthatterminaldiseases
andmortalityaremattersultimatelybeyondhumancontrol
andprofessionalmastery.

80. 80
QUIZ
14.The__________right torefuseorwithdrawmedical
treatmentinvolvesanunderstandingthatterminaldiseases
andmortalityaremattersultimatelybeyondhumancontrol
andprofessionalmastery.
A.Negative c.Other
a.Positive d.Patient

81. 81
12.Theimplicitintentionalityinsuchdecisionsisto
ceasefutiletreatmentsthatpresentminimalprospectof
benefitsand/orimposedisproportionateburdenstothe
patientandsimultaneouslyaffirmthatcomfortcareis
neverfutileandalwaysmorallyrequired.

82. 82
13.Inthecontextsofphysician-assisteddeath,and
especiallymedically-assisteddeath,humanagencyis
directlyinvolvedasthecausalagentofdeathandthe
intentionalityoftheactionsistoendthepatient’slife
throughmedicalexpertiseandtechnologies.
14.Theterminallyillpatientretainsthefinalchoiceto
ingestthemedicationinphysician-assisteddeath-

83. 83
(approximately1/3ofpatientschoosetonotusethe
medication),amatterofagencythatethicallyand
professionallydistinguishesthispracticefrommedical-
assisteddyingprovidedbyahealthcareprofessional.

84. 84
15.Thefallacyofethicalequivalencebetweenphysician-
assistedandmedical-assisteddeathisalsoevidencedbya
broadenedandsubjectiveinterpretationoffutility.The
morallogicoftherighttodiewasinitiatedbyjudgments
thatcertainmedicalinterventionswerefutileintermsof
patientrecovery.

85. 85
16.Thepracticeofmedical-assisteddyingexpandsthe
conceptofaprofessionaljudgmentoffutilityregarding
extendinglifetofutilityinrelievingphysicalor
mentalsufferingaccordingtopatientcriteria.
17.TheCanadianlawisveryclearinitsintenttoshift
thecriteriaformedical-assisteddyingawayfroma
professionaljudgmentofaterminaldiagnosis-

86. 86
(aswiththeUSstatutes)toanindividualizedandnecessarily
subjectivepatientassessmentoftheirillnessexperience.
18.Itfollowsthatifapatientdeterminesthattheir
sufferingfromanon-terminalconditionisirremediableand
cannotberelieved,theprofessionalresponsibilitytorelieve
sufferingisironicallyfulfilledbyendingthelifeofthe
sufferingperson.

87. 87
QUIZ
15.The_________lawisveryclearinitsintenttoshift
thecriteriaformedical-assisteddyingawayfroma
professionaljudgmentofaterminaldiagnosis-(aswith
theUSstatutes)toanindividualizedandnecessarily
subjective patient assessment oftheir illness
experience.
a.Indian c.Switzerland
b.Norway D.Canadian

88. 88
19.Itisincumbentonthemedicalprofessiontobeableto
offermoretopatientswithaseriousorterminalillness
thaneitheraggressiveandinvasivemedicalinterventionsor
hasteningthepatient’sdeath.
20.Asarguedbyphysician“EricCassell,”the“testofa
systemofmedicineshouldbeitsadequacyinthefaceof
suffering,”evenifidentifyingandbeingpresenttopatients
whoaresufferingisaveryelusiveexperience.

89. 89
21.Physiciansassumeacriticalethicalresponsibilityfor
compassionatelyandempatheticallyhearingthenarratives
patientstellastheyarefacedwithsuffering,critical
illness,dying,andmortality,storiesthatoftenreflect
themesofrestoration,chaos,journey,andidentity.
22.Arelianceontheartofhealingandthewisdomof
generationsofprofessionalcareinthemidstofthe-

90. 90
ordealofsufferingispartofwhatphysicianPaul
Kalanithidesignatedasthe“mortalresponsibility”
physiciansassumeashealers.

91. 91
Professional Integrity

92. 92
a.Partofthecatalystforthemorallogicoftheright
todiethataimstoexpandpatientchoicesinend-of-life
careisthatmedicaltechnologies,professionalcontrolof
dying,andmedicalizationhavemadeithardertodieinthe
contemporaryera.
b.Theascendantmedicalizationofdyingisintimatedinthe
languageofmedicalassisteddyingselectedbyadvocatesto
portraywhatoccurswhenapatientmakesa-

93. 93
requestofahealthcareprofessionalforaprescription
orthedirectadministrationofalethalmedicationto
hastendeath.
c.Themedicalizinglanguagereflectsandextendsthe
domainofmedicineoverthedyingprocessratherthan
extractingpatientsfromtechnological,institutional,and
professionalcontrol.However,integratingphysician-
assistedormedically-assisteddyingaspartofthebest-

94. 94
practicesthatmedicinehastoofferinend-of-lifecare
symbolizessomethingpowerfulandalsoperplexingaboutthe
natureofmedicine.
d.Medicinehashistoricallybeenrepresentedasa“healing
profession,”with“healing”asthedefiningfeatureofthe
professionalvocation,asmanifestedthroughpurposesof
caring,curing,preventingprematuredeath,promotinghealth,
andrelievingunnecessarypainandsuffering.

95. 95
e.Thedistinctive“profession”orpromiseofmedicineis
definedbygoodsandvaluesinternaltotheprofessional
ethosandpractice.
f.However,physician-assistedandmedical-assisteddying
inevitablymakethecaring,curing,relieving,andhealing
purposesofmedicinesubservienttoothergoals,especially
thosedefinedbypatientpreferences, extrinsicto
medicine’sprofession.

96. 96
g.Whatmedicineisvaluedforprimarilyinphysician-and
medical-assisteddyingistechnicalproficiencyand
functionalityinprovidinganeffectiveandexpedient
means(alethalpharmacologicagent)toachievethe
patient’sendofahasteneddeath.
h.Thehealingvocationofthephysicianisdiminishedto
theroleofefficient,andmorallyneutral,technician.

97. 97
QUIZ
16.Thedistinctive“_________”orpromiseofmedicineis
definedbygoodsandvaluesinternaltotheprofessional
ethosandpractice.
a.Avocation C.Profession
b.Idleness d.Use

98. 98
I.Theconstructionofmedicineasamorallyneutral
technicalpracticethatservesendsdeterminedby
patientsisreinforcedbyculturalshiftsthatemphasize
thecharacterofmedicineasa“business,”healthcareas
an“industry,”andrelationshipsofpatientandphysician
asa“retail”transactionbetween“consumers”and
“providers”.

99. 99
j.Advocatesoflegalizationhaveappropriatedtheconsumerist
constructionoftherelationshipbecauseitpresupposesthe
primacyofpatientpreferenceandchoice.
k.However,aswithanyretail-orientedrelationship,themoral
valenceofthepatient-physicianrelationshipisdiminishedto
animpersonaltransactionalexchangebetweenstrangersinwhich
thecentralethicallybindingfeatureofmutualtrustis
ethicallyperipheral.

100. 100
L.Theethicalimplicationofthebusinessconstruction
of medicine and the consumerist transactional
relationshipbetweenpatientandphysicianisthat
medicine’sintegrityandmoralidentityisdependenton
culturalfactorsextrinsictothehealingpromiseofthe
profession.

101. 101
M.Thesensethatmedicineandmedicalprofessionalismhas
itsownethicindependentofsocietalconsiderations,
politicalinfluences,orpatientchoicesinpartexplains
whyAmericanjurisdictionsthathavelegalizedphysician-
assisteddeathhaverefrainedfromadopting(fornow)a
Canadian-stylemedical-assisteddeathprocedure.

102. 102
N.Physicianshavereasonedthatbyprovidinga
prescription, their personal involvement and
responsibilityforapatient’sdeathisindirectatbest,
in sofar as a patient assumed additional
responsibilities,includingobtainingtheprescription
anddecidingwhetherornottoingestthemedicationby
self-administration.

103. 103
QUIZ
18.The__________implicationofthebusinessconstructionof
medicineandtheconsumeristtransactionalrelationship
betweenpatientandphysicianisthatmedicine’sintegrity
andmoralidentityisdependentonculturalfactors
extrinsictothehealingpromiseoftheprofession.
a.Unethical c.Undignified
B.Ethical d.Unrighteous

104. 104
O.Whilediminishingthephysician’sroletothatof
technician, this professional distancing from
responsibilityforapatient’sdeathcannotberetained
whenaphysician(ornursepractitioner)participatingin
clinically-administeredmedicalaidindyingbringsabout
thepatient’sdeaththroughdirectadministrationofthe
lethalagent.

105. 105
P.Furthermore,theprofessionalcommitmentthatmedicineis
morallymorethanaconsumer-directedretailtransactionis
whyalljurisdictions(includingCanada)thathavelegalized
someformofphysician-assistedorclinically-administered
aidindyinghaveallowedphysicians(andotherhealthcare
professionals)toexerciseclaimsofconscientiousrefusal
anddeclinetoparticipateinthepatientrequestor
procedure.

106. 106
Q.Theincorporationofphysician-andmedical-assisted
dyingpracticesasoneservicetheprofessionnowoffers
patientsentailsatransformativere-conceptualizationin
medicineofitsprofessionalintegrityandethics.

107. 107
Social
Responsibilities

108. 108
1.Itisapuzzlewhythereisgreaterpublicadvocacyfor
therighttodieandlegalizedphysician-assisteddeath
and/ormedical-assisteddeathinasocietythathas
continuallyfallenshortofguaranteeingitscitizens
universalaccesstobasichealthcare.
2.Itappearsethicallyperversetoadvocateequalaccess
todeathintheabsenceofequalaccesstohealthcare.

109. 109
3.Significantly,everynationthathaslegalizedmedical-
assisted dyingandphysician-administered euthanasia,
includingnotonlyCanada,butalsoBelgium,theNetherlands,
Switzerland,andstatesinAustralia,hasasystemof
universalizedaccesstohealthcare.
4.TheUSfailuretoprovidethissafetynetofbasichealth
careforall,whileproceedingtolegalizephysician-assisted
deathandconsiderproposalsformedical-assisteddeathis
furtherevidencethatAmericanhealthcareisneither
healthy,norcaring,norasystem.

110. 110
4.AnnualhealthcareexpendituresintheUShavereacheda
staggering$3.4trilliondollars,astunning18percentof
thenation’sGDP.Thesubstantialportionoftheseexpenses
aredevotedtowhatcanbedesignatedas“sickcare,”that
is,treatmentsorinterventionsintendedtorestoreasick
persontogoodhealthandqualityofliferatherthan
preventivecarethatpromotesaperson’s--

111. 111
health and keeps them out of the clinical or hospital
setting in the first place.

112. 112
5.Furthermore,studiesindicatethatover25percentof
totalMedicarecosts,orapproximately$170billion,are
devotedtomedicalcareandinterventionsduringthe
lastsixmonthsofaperson’slife,oftenwithminimal
medicalbenefittothepatient,evenifthisprovides
psychologicalbenefittofamilymemberswhoareassured
theyhave“triedeverything.”

113. 113
QUIZ
19.Itisa________whythereisgreaterpublicadvocacy
fortherighttodieandlegalizedphysician-assisted
deathand/ormedical-assisteddeathinasocietythat
hascontinuallyfallenshortofguaranteeingits
citizensuniversalaccesstobasichealthcare.
a.Clear c.Straightforward
B.Puzzle d.Comprehensible

114. 114
6.Thiscost-ineffectivespendingpatternhasmadeendof-life
medicalcareandinterventionsaprimeareaforproposingcost-
containmentprocesses.
7.Inthiscontext,effortstolegalizephysician-assisted
deathormedical-assisteddeathmayseemtoprovidea
utilitarian-orientedresolutionbyprovidinganalternativefor
patientstoendtheirlifeandsparetheirfamiliesandthe
societyofsignificantmedicalexpensesduringtheirdying
process.

115. 115
8.Itisimportantingeneraltocommendpersonswhomake
sacrificesoftheirintereststobenefitthecommongood.
However,thevalueanddignityofhumanlifemorally
shouldnotbereducedtoaneconomiccalculation.

116. 116
9.Afirewallmustbemaintainedbetweendecisionsabout
endinglife,beitthroughrefusingtreatmentoralife-
endingmedication,andthecostsofcare.Intheabsence
ofsuchafirewall,whathasbeenadvocatedasarightto
diecanbeexperiencedasadutytodieonbehalfof
otherpersonsorbroadercommunities.

117. 117
QUIZ
20.Intheabsenceofsucha________,whathasbeen
advocatedasarighttodiecanbeexperiencedasaduty
todieonbehalfofotherpersonsorbroadercommunities.
A.Firewall c.Standstill
b.Pull d.Policy