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Autonomy and Not for Resuscitation Order

Analyse legal and ethical issues relating to Not for Resuscitation by evaluating a case study.

Medical professionals take an oath that they did not harm any people or breach the sanctity of human life by purposely killing a person. They are expected to do whether in their power to ensure they save the life of a patient. The ethical codes of medical field deal with common elements which include honesty, respect for patient autonomy, respect for the law, non-maleficence, confidentiality, beneficence and distributive justice (Percival, 2014). Ethical dilemmas in medical field arise when there is a conflict between two ethical principles. Euthanasia is referred to the killing of a patient in order to relieve him from the pain which he/she is suffering from an injury or disease which cannot be treated by medical professionals. This concept has caused many controversies in the medical field because there are a number of ethical and legal issues relating to the same. The concept contravenes the principle of resuscitation which is referred to a process of reviving a person’s life especially from apparent death or from unconsciousness. The advancement in the medical field has increased recoverability from untreatable conditions, for example, cardiopulmonary resuscitation (CPR). Not for resuscitation (NFR) or do not resuscitation (DNR) is referred to an order which prohibits a medical professional from performing CPR on an individual (Mentzelopoulos, Haywood, Cariou, Mantzanas & Bossaert, 2016). The thesis contributes to debates regarding ‘Not for Resuscitation’ order by evaluating different legal and ethical issues with the same and understanding its importance to save a person from suffering. This essay will provide different arguments regarding the legal and ethical issues relating to NFR and critically analyse its principles to provide advice in the given case study. This essay will evaluate the four ethical principles of Beauchamp and Childress to provide advice to the family of Dawn.


Based on the principle of autonomy, an order for NFR should be valid because its motive is to stop the suffering of a person. But, a medical professional takes an oath to protect the lives of others and not to cause any harm to another individual. However, as per the American College of Emergency Physicians (ACEP), the medical professionals are not obligated to provide treatment to a person who will not have any realistic medical benefit by the treatment (Marco, 2005). It means that if the medical professional is certain that the treatment will not assist in improving the health of a person than he/she did not have to provide such treatment. In particular, while deciding on euthanasia, the party has to consider the legal and ethical issues. The principle of autonomy provides that a patient has the independence to determine the direction which he/she decides to take as long as he/she has his legal rights. Ethically, a patient should be treated autonomous, and he had the right to voluntarily select the treatment and procedures which include life support and euthanasia, but it is important that the person must make his/her wish known even if the family members oppose it (Albtoosh & Mrayyan, 2014). In this case, Bronwyn told that Dawn mentioned her that she did not want to live like a vegetable for the rest of his life and she would rather die in comfort than living in suffering for a long time. As per the ethical principle of autonomy, an order for NFR can be issued in this case because Dawn make her wish known and the opposition of her family does not matter. Thus, an order for NFR is an ethical decision for the medical professionals in this case.

Beneficence and Euthanasia

In case the medical professionals believe that there is not proper palliative care available which is able to cure the patient than they can consider euthanasia in order to ensure that the patient is not suffering from pain. The concept of euthanasia has become popular based on the concept that people have the right to decide whether or not they should live or not. It has been argued that euthanasia is not necessary in case appropriate palliative care is available for a patient and he/she can relive his/her pain by taking medicine (Coombs & Grech, 2016). However, if the disease or injury is untreatable, then an order for euthanasia is ethical especially if the patient is suffering from pain. The ethical or moral theory obligates a medical professional to know what is best for the welfare of others which include eliminating harm to another party by taking the decision which is in the best interest of the patient. The principle of beneficence applies in the case when a person in permanent vegetative state and the life support is not long for the best benefit for the patient. By keeping the patient’s best interest in mind, the doctor decided to end the suffering of the patient through euthanasia because it is the right or moral thing to do at such moment (Cameron-Taylor, 2014). Preventing or reducing the suffering of a person is considered as an act of mercy and beneficence. In the case of Dawn, her doctor has clearly mentioned that she is in a permanent vegetable state and she is suffering from a lot of pain as well. The nurse mentioned to the family that the hospital will ask advice from an independent medical expert or the family can appoint a doctor themselves to get a second opinion on the situation of Dawn. Based on such opinion, the family should take the right decision which is in the best interest of Dawn. Therefore, it can be concluded that according to the doctor, removing the life support of Dawn will be more beneficial for her and it will be an act of mercy and beneficence.


It is argued that the actions of a medical professional must be non-maleficence and euthanasia could be considered as maleficence but if its purpose to prevent the pain of an individual, then it is considered as non-maleficence. The oath which is taken by medical professionals is considered as Hippocratic Oath because it provides that a physician should treat a person to the best of one’s ability and preserves a person’s privacy and above all, do not harm (Levinson, Ho, Mills, Kelly, Gellie & Rouse, 2017). However, an ethical dilemma arises when a patient is suffering from an untreatable disease or injury, and the medical professional knows that the life support system is no longer useful and the patient will be in a vegetable stage for his whole life. The theory of non-maleficence forbids a medical professional from inflicting any evil or harm on another person, and it is his/her obligation to protect people from harm. Based on this theory, the doctor should do whatever in his power to treat his/her patients to the best of his/her knowledge. But, when treatment becomes useless or ineffective, it resulted in causing more harm to the patient then saving his life. Even successful resuscitation cause severe damages to the lungs, brain or heart of the patient due to which the death could occur in a matter of hours or days (Gulacti & Lok, 2016). Similarly, the patient who is in permanent vegetable stage might suffer from more pain when he/she is on the life support. Therefore, in order to avoid such pain and making it more comfortable for the patient, the doctors choose the route of euthanasia. In the case of Dawn, the doctor has clearly stated that her condition will not improve in the future at all. Currently, she is also suffering from substantial pain which makes the life very uncomfortable for her. If the doctor keeps her on the life support, then she is more likely to suffer from such pain for a long time. The opinion of an independent doctor will also be considered in the case before taking any decision. Based on which the decision of the doctor is non-maleficence, and it is the right decision for Dawn as it is her right as given in the judgement of In re Quinlan (70 N.J. 10, 355 A.2d 647 (NJ 1976)) (Dunn, 2015).

Non-Maleficence and Euthanasia


The decision of NFR or DNR should be focused for the justice of the patient that means that the decision should be just and fair for him in the particular situation. While deciding another person’s life, it is necessary to ensure that the decision is just and fair and for the benefit of the party. Similarly, the decision of euthanasia should not be based on any malice or deceptive action which could negatively affect the patient (Mickiewicz, Krajewska, Kulak & Lewko, 2012). While deciding whether an order for NFR or DNR should be issued, the principle of justice is must element without which a decision for euthanasia is illegal. In Australia, euthanasia is illegal under the federal law however many states have legalised euthanasia after evaluating the circumstance to evaluate whether it is just to the patient. In the judgement of Cruzan v Director Missouri Department of Health, 497 U.S. 261 case, the court provided that it is unjust to accept euthanasia, especially in the case when there is lack of evidence available to make a proper judgement (Maillet, Schwartz & Posthauer, 2013). Based on lack of evidence an application for euthanasia cannot be accepted, and it is considered as unjust. The concept of justice emphasises equality and fairness among people. The medical professionals are required to ensure that they did not make any discrimination between patients based on any factors and they should be fair while giving them treatment (Green, 2014). In the case of Dawn, the doctor has provided that she will be in a permanent vegetative state for the rest of her life and she is also suffering from a lot a pain. She had told her daughter that rather than living like a vegetable for the rest of her life, she would rather prefer to die comfortably. Furthermore, the doctor believes that there is no treatment available for Dawn and she will be like this for the rest of her life. The medical professionals believe that removing her from life support will be merciful and beneficence for her because it will avoid the pain that she is suffering and make her more comfortable. The doctor is also ready to hear a second opinion of an independent doctor to ensure that the decision of euthanasia is suitable for Dawn; therefore, the actions of doctor are non-maleficence. Thus, based on these factors, it is just and fair to remove dawn for life support because it will avoid her pain and make her more comfortable.

Justice and Euthanasia


In conclusion, there are a number of legal and ethical issues relating to accepting an order of ‘Not for Resuscitation’; however, it is justified if its purpose is to end the suffering of the patient. There are a number of ethical principles which are necessary to be considered in a particular case in order to accept the order of ‘Not for Resuscitation’. The autonomy of the patient is a key factor because he/she has the right to decide whether or not the life support system should be removed or not. The element of beneficence is important which means that the doctors must decide by considering the best interest of the patient. The decision must be based on non-maleficence, and the purpose of the decision should be to end the suffering of the patient. Furthermore, the decision of euthanasia should be based on the principle of justice which means it must be just and fair for the patient. In the case of Dawn, she had told her daughter that she would rather die in comfortable than live like a vegetable. The doctor is acting for the benefit of Dawn and in order to end her suffering. The nurse will consider the opinion of an independent doctor in order to ensure that the decision is non-maleficence. Based on these factors, if the doctors suggest that euthanasia is right for Dawn, then her family should accept their decision because it is just and fair for Dawn.

References

Albtoosh, L., & Mrayyan, M. (2014). Policy Analysis Paper: Do Not Resuscitate (DNR) Policy. SSRN.

Cameron-Taylor, E. (2014). The Palliative Approach: A Resource for Healthcare Workers. M&K Update Ltd.

Coombs, M., & Grech, C. (2016). Ethical issues in critical care. ACCCN's Critical Care Nursing, 106.

Dunn, G. P. (2015). Surgery, palliative care, and the American College of Surgeons. Annals of palliative medicine, 4(1), 5-9.

Green, T. E. (2014). Autonomy and the possibility of perioperative euthanasia. British journal of anaesthesia, 112(6), 1124-1125.

Gulacti, U., & Lok, U. (2016). Influences of “do-not-resuscitate order” prohibition on CPR outcomes. Turkish journal of emergency medicine, 16(2), 47-52.

Levinson, M., Ho, S., Mills, A., Kelly, B., Gellie, A., & Rouse, A. (2017). Language and understanding of cardiopulmonary resuscitation amongst an aged inpatient population. Psychology, health & medicine, 22(2), 227-236.

Maillet, J. O. S., Schwartz, D. B., & Posthauer, M. E. (2013). Position of the Academy of Nutrition and Dietetics: ethical and legal issues in feeding and hydration. Journal of the Academy of Nutrition and Dietetics, 113(6), 828-833.

Marco, C. A. (2005). Ethical issues of resuscitation: an American perspective. Postgraduate medical journal, 81(959), 608-612.

Mentzelopoulos, S. D., Haywood, K., Cariou, A., Mantzanas, M., & Bossaert, L. (2016). Evolution of medical ethics in resuscitation and end of life. Trends in Anaesthesia and Critical Care, 10, 7-14.

Mickiewicz, I., Krajewska, E., Kulak, W., & Lewko, J. (2012). Attitudes towards euthanasia among health workers, students and family members of patients in hospice in north-eastern Poland. Progress in Health Sciences, 2(1), 81.

Percival, T. (2014). Medical ethics. Cambridge: Cambridge University Press.

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