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Background reading material for Year 2 Semester 1 medical students for PPSD session on 23rd August 2006 by Professor Omar Hasan Kasule, Sr.
LEGAL DEFINITIONS OF TERMINAL ILLNESS AND DEATH
Terminal illness is defined as illness from which recovery is not expected. The manner in which death is defined affects the legal position about life support. The following are various definitions of death: (a) traditional: cardio-respiratory arrest (b) Whole-brain death (c) Higher brain death. If death is defined in the traditional way, life support cannot be withdrawn at any stage. If the definition of higher brain death is accepted, life support will be removed from persons who still have many life functions (like respiration, circulation, sensation). The question of quality of life is also raised in the definition of life. The assumption is that there must be some quality to human life for it to be worth living. The exact definition of quality is still elusive.
CERTAINTY
Since the definition of death and the exact time of its occurrence could be uncertain, a major irreversible decision like withdrawing life support cannot be taken in cases of doubt. The Law strictly forbids action based on uncertainty. A question also arises as who makes the decision to withdraw decision because the patient is usually unconscious and in not competent or capacitous.
THE RIGHT TO LIFE vs RESOURCE CONSERVATION
The purpose of preserving life may contradict the purpose of preserving resources. Life comes before resources in order of priorities. This however applies to expenditure on ordinary medical procedures and not heroic ones of doubtful value in terminal illness. Such expenditure may be considered a waste of wealth especially if there are competing demands for scarce resources.
LEGAL RULINGS ON INITIATING and WITHDRAWING LIFE SUPPORT
The patient's choices about food and medical treatment my contradict the purpose of preserving life. Where life is under immediate threat, the patient's desires may be overridden. The terminally ill patient, who takes a major risk, should make the final informed decisions after clarification of the medical, legal, and ethical issues. The family may request that life support be terminated if the patient is in pain or coma but this may be open to question. Self-interest may motivate some members of the family and others with personal interest to hasten the legal death of the terminally ill patient. Physicians and other health care givers may abuse withdrawal of life support.
WITHHOLDING vs. WITHDRAWAL
A distinction in law exists between withholding life support and withdrawing it. The issue is legally easier if life support is not started at all according to a pre-set policy and criteria. Once it is started, discontinuation raises legal or ethical issues. The principle of the law that applies here is that continuation is excused where commencing is not. Continuation is easier that starting.