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Presentation
to 4th year medical students at Salman University Kharj on 14th
May 2013 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traditional way, life support cannot be withdrawn at any stage.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.