Death and Dying:

Principles, Issues and

Concerns
Jerry Reb. Manlangit, OP., MHA, PhD
Professor, University of Sto. Tomas
Graduate School
Ecclesiastical Faculties
Faculty of Medicine and Surgery
 Issues in the Care of the Terminally-ill:
When the patient is terminally-ill, is it ethical to remove
LSD or other interventions even when these are the only
means that keep him alive?
When you remove these interventions, and the patient
dies, don’t we kill him?
If the interventions just prolong the dying process, is it
ethical to continue applying them?
Can the family ask the AMD to withhold or remove LSD on
a terminally-ill patients?
When do interventions considered ordinary or
extraordinary?
When the decision to remove LSD has been agreed upon,
who will do it?
Who should give consent?
Should health care givers honor advanced directives of
patients? (Wills, Living Wills, DPA, etc.)
Imp. things to consider in the care of the
terminally-ill
cultural and religious values
marital and familial issues
view of life
- young
- adult
- old age
view of medicine
view of pain and suffering
view of death
 Goals assigned to Medicine:
Preserving life, preventing disease,
maintaining health and relieving pain and
suffering

In addition, the duty to seek, within moral

means to a decent, peaceful death, which is
an aspect of the duty to try to relieve
suffering. (Daniel Callahan)
Why should we preserve, protect,
defend, develop and enhance life?
Obviously,
life is
valuable
and
sacred.
cont. . . .
It is a gift from
God who is a
generous giver.
By the principle of
stewardship, we
are given a shared,
not an absolute
dominion over our
life.
 Why is life sacred?
It comes from a holy God and goes back to
a holy God.

Because its source is divine and its end is

divine.

Life is not only a physical body but also a

spiritual soul.
 Human
life is the
only
creature
in this
world
with
DIGNITY.
What are the
bases of human
dignity?

1. Created in the image and likeness

of God.
2. (For Christians) Man was the
reason why Christ came into the
world.
3. He has a noble destiny to fulfill.
4. He has a rational and moral nature.
Why does man
suffer?
Philosophically,
because his
nature is
limited,
imperfect and
weak.
Suffering: A state of
a person
undergoing
painful or
distressing
feeling. It
is a sign of
human
helpless-
ness.
On a deeper spiritual level, man suffers
in order to . . . .
reminds him
of his self-
insufficiency
and
dependence
on the power
of his Creator.
 The Value of Suffering:
1. Realizes sinfulness and its
consequences
2. Sees the real value of things
3. Makes one empathetic to others
4. Realizes the temporality of the world
5. Makes one prayerful
6. Highlights frailty of human being
7. Develops noble virtues of man
8. Distinguishes the temporary from
the permanent values
9. Draws interest to the true God
 The
principle
of
Growth
through
Human
Suffering
“As bodily pleasures should be
sought as the fruits of the
satisfaction of some basic need
of the total human person, so
suffering and even bodily death
when endured with courage can
and should be used to promote
personal and social growth,
maturity and even as means to
freedom.” (B. Ashley & K. O’Rourke)
 Categories of Terminally-ill Patients:

Patients with terminal illness whose death is imminent

(probably within one month)

Patients with terminal illness whose death is not imminent

but who are faced with a current acute life threatening
crisis (massive stroke, cardiogenic shock, septicemic
shock)

Patients on a PVS whose condition is irreversible (no

cerebral cortical function)
 FATAL PATHOLOGY:
Any disease,
illness or
injury which
will cause
death if
allowed to
run its
course.
 IN THE PRESENCE OF FATAL PATHOLOGY, THE
DUTY TO PRESERVE LIFE IS ASSESSED:

* Will the intervention be effective?

* Will the intervention cause serious
burdens?
Suffering (pain)
Effort
Psychological/emotional burden
Financial burden
* Will the burden imposed by intervention
seriously impede achieving life’s
purpose?
 IF THE TREATMENT TO
CURE/ALLEVIATE
PATHOLOGY IS:

Effective and does not impose

grave burden – it must be utilized.
Ineffective or non-beneficial – it must not be
used.
Effective but imposes grave burden – it may
be withheld or withdrawn.
 Implications of Disconnection
of LSD:
When LSD is disconnected the patient dies?
Implication = LSD is useless

When LSD is disconnected the patient survives?

Implication = LSD is useless

In either case: There is moral justification in the

disconnection of LSD.
 In such circumstance,
the intention is not to kill
the patient but simply to
avoid doing something (a
medical intervention) that is
useless or futile.
(This is good medicine!)
 Loeb’s Law in Medical Care:

If what you do, works – continue doing it.

If what you do doesn’t work - stop doing it.

If you do not know what you’re doing - don’t do

anything at all.

The treatment should not be worse than the

disease.
 Remember the two eminent
duties of the physician, namely:

The Principle of Beneficence:

“Always do good.”

The Principle of Non-maleficence:

“Do no harm.”
 MISUNDERSTANDINGS:
Misunderstanding of certain issues:
– Killing/allowing to die
– Withholding/withdrawing life
support
– Ordinary
or extraordinary
means of life
preservation
 Principle in the Use of
Ordinary and Extraordinary
Means
Extraordinary – refers to interventions that do not offer any
reasonable hope of recovery, or that which makes care unreasonably
burdensome.

Ordinary – refers not only to nutrition, hydration or respiration but

also to any treatment or intervention that offers reasonable hope of
recovery, or that does not make care unreasonably burdensome.

Ethical duty: We are not normally bound to use extraordinary means

based on the duty “to promote good and avoid evil or harm as it is
possible in the situation.”
 Distinction of the ff.:
Euthanasia:
- active
- passive

Dysthanasia

Orthothanasia
Hippocrates:
Good medical
care:
cures
sometimes
relieves
often
comforts
always
 Notes to ponder:
We are not obliged to keep everyone alive.

Death of a patient is not a failure of medicine

nor the doctor (unless proven that negligence is
present)

Death can occur even in the best of hands or

best medicine.

What is important is doing what is best for the

interest of the patient (whether he dies or not).
 Further Notes to Remember:
When medical care fails, not everything ends or
fails.

There is palliative care that is still available.

There is comfort care that everyone can do.

What is important is never abandon the patient

in his most crucial moments.
 St. Peter 5:7 (on his advise with the
terminally ill and dying patients)

“Cast all your cares on

God because He cares for
you.”
Why does man die?
Obviously,
because man is
not omnipotent.
He has
limitations,
imperfections
and
weaknesses.
 Theologically, because he is not
meant for this world, though he is in this
world. He is meant for something
greater, fit for his higher spiritual nature.
He is therefore destined for a place
beyond this world. This is what makes
life meaningful, for life is not merely
earthly but heavenly. It is not only to
perfect him in his human form but much
more so in his divine form.
 Stages in the Dying Process
(stages of Grief)
• Denial
• Anger
• Bargaining
• Depression
• Acceptance or Hope
Elizabeth Kübler Ross, On Death & Dying
What is
death?
 Medically:

1 - When disease or illness overcomes

the human organism.

2 - When vital organs necessary for life

cease to function permanently,
(e.g. entire brain incl. brain stem)

3 - Irreversible loss of
cardiorespiratory function.
 Philosophically:
It is the stoppage of self-motion.

When the physical body reaches

its final subjection to physical
corruption and decay.
 Theologically:

It is a rite of passage.

It has a beautiful message.

It is a great heritage.
Eccl 3:2
“Death is part of the
narrative or story of the
life of every human being,
a mortal being.” It is
therefore not the end of
everything. It is a part of a
seamless cloth.
Jorge Manrique:

For man to want to live

when God wants him to
die is madness. (Que querer
hombre vivir quando Dios
quiere muera es locura).
Rabindranath Tagore:

“Death is extinguishing
the light because the dawn
has come.”
What is life meant for?

BEATITUDE
WITH THE
CREATOR
What is beatitude?
It is a state
of harmony,
peace,
happiness
and
satisfaction.
In the care of the terminally ill, one has to remember
that. . . .

The cost of combating the

human problems of
loneliness, infirmity,
depression and human
death is not self-
destruction, rather the
development of a
compassionate, caring and
generous community. The
doctors are necessarily
and naturally the leaders
in this distinct task.
“No medical solution could be truly
compassionate which would violate
the natural law and stand in
opposition to the revealed truth of
the word of God. In the end, we
must recall that no doctor, no
nurse, no medical technician,
indeed no human being, is the final
arbiter of human life, either of
one’s own life or that of another.
This realm belongs only to God, the
Creator and Redeemer of us all.”

Pope John Paul II

Address to Anesthesiologists
 Last question?

Who disconnects the LSD?

 Case
Mrs. Lopez is a 72 year-old widow with three adult children and ten
grandchildren. She was rushed to the hospital due to cardiac arrest. Eventually,
she was hooked onto a ventilator and is in the state of coma. Dr. Lab informed
the children that Mrs. Lopez is in a critical condition and he cannot do anything
about it and explained further that hers is a terminal case. The ventilator will
only prolong her life and suffering. The eldest daughter signed a waiver in favor
of DNR if another arrest comes through. In the meantime they decided to bring
their mother home. And Dr. Lab responded, “Who among you could pull out
the ventilator?” The three children looked at each other and said, “We’ll think
about it.” After a while, they brought Angelica, a four year old daughter of one
of Mrs. Lopez’ children to the Doctor with the view to letting her pull out the
plug. It was done. Mrs. Lopez was pronounced dead ten minutes later.

A. Was the decision to pull out the ventilator ethical? Why?

B. Was the actuation of Doctor Lab ethical? Why?
C. Was the decision to let Angelica pull out the ventilator ethical or not? Justify?
 U!
YO
NK
H A
T
 LAST WILL AND TESTAMENT

Requisites:

- being the last decision made by the legitimate maker

before death or before loss of competence.
- competence needed by the maker; major age
- it can be amended and the newest will and testament
supersedes the old.
- names of beneficiaries (%)
- must be respected or honored
- written (notary public) or holograph
- witnesses (testators)
- disposition of property after death
- the case of religious with vows
 ADVANCED DIRECTIVES

Advanced Directives: (on Health Concerns):

- A written document by a legitimate person that directs

those who have been given the authority through a Durable
Power of Attorney or DPA to make decision for one’s health
when one loses competence or decisional capacity.
Sometimes this is done through verbal instruction/s but
must be signed by witnesses.
With notary public or holograph
 LAST WILL AND TESTAMENT

Examples:

- properties/inheritance

- future assets

- in accordance with law on inheritance

 ADVANCED DIRECTIVES

Examples:

- Cremation

- No CPR when one falls into an irreversible

coma or multiple CPR.

- Need for an independent Neurologist to declare

irreversible coma or clinical death (brain death)

- no extraordinary measures
G God looked around His garden and He found an empty
O place.
D He then looked upon this earth, and see your tired face.
’ He put His arms around you and lifted you to rest.
S God’s garden must be beautiful. He always takes the
best.
G
He knew that you would never get well on earth again.
A That in us you will be absent, but in God you will
R certainly be present.
D
He saw that the road was getting rough and the hills are
E hard to climb.
N So He closed your weary eyelids and whispered “Peace
be thine.”
 Case

Your aunt is in an irreversible coma,. But has

been given nourishment and hydration through
intravenous (IV) DEVICES. She is also hooked on a
respirator which is the only device that sustains her
respiration. The physician suggests that the
respirator be removed, allowing her to die of
natural causes. You object because you believe that
would be tantamount to killing her. How could a
physician convince you that such withdrawal of life
sustaining device is morally sound?