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1. A patient in terminal condition treated with emotional understanding and respect, without futile therapy, in a family (or family-like) environment, in conditions that contribute towards a dignified, socialised, recognised and accepted death:
This is the common situation with people of a very advanced age, who receive support from their families or from a quality social establishment, who do not suffer any curable disease but only senility or the irreversible sequelae of cardiac or cerebral vascular incidents.
In such cases, the medical decision to practise caring medicine complies with the ethical principles quoted above.

2. A patient in hospital, in serious condition, who progresses to a terminal stage.
The health care team, being devoted and competent, decides to interrupt treatments that clearly have become inefficient according to the best clinical judgement, refusing therapeutic stubbornness as bad medical practise, using nevertheless every necessary means to ensure the comfort and well-being of the patient, so that the process of dying may unfold with respect for the dignity of the human person.
For such a medical decision to be correct, it is necessary that:
during the final period, the health team attend to the patient in a constant and personalised manner;
the presence of relatives be permitted 24 hours a day, as well as that of other people who the terminal patient might wish to see, including ministers of religion;
discharge from hospital be facilitated in the final stage, if the patient or the patient’s family so wishes.
As long as these requirements are complied with, death in a hospital environment (or outside it) can occur with respect for human dignity, and the medical decisions concerning it will be ethically correct and good medical practise.
In the light of the principles quoted above, it is ethically unacceptable that the terminal patient should be isolated and abandoned until death occurs in utter loneliness.

3. A patient considered (or considering him/herself) terminal or incurable, or one humiliated by the disease, or one who has lost the will to live, who asks the attending physician or another member of the health care team or any other person (a relative or someone else) to be provided with a substance for self-administration which is known to be fatal.
A positive decision, in this case, would constitute aiding and abetting a suicide.1
This is not the place to judge, from an ethical point of view, the decision of the person who asks to be killed, for that decision is deeply intimate and personal.
The decision to accede to the person’s wish, providing the means with which to kill him/herself, has no ethical justification. Whoever receives the request must not accept, therefore, that the person ought to commit suicide, nor contribute to the satisfaction of a wish that is extraneous to the recipient and which results in the destruction of a human life.

4. A patient who does not wish to live because he/she considers intolerable the quality of life open to him/her, who is psychologically competent to exercise personal autonomy, and insistently asks the attending physician (or another person) to kill him/her using drugs or other means.
If the physician (or another person) accedes to that request and kills the patient because of that request, he/she will be practising voluntary active euthanasia.
As in the previous case, we must not make ethical judgements about the decision of the person who freely exercises personal autonomy by making the request.
On the other hand, the way in which the decision to accede or not to the patient’s insistent wish takes form in the physician’s professional and moral conscience certainly merits careful ethical reflection.2
For many MD’s in Portugal, the fact that this is a homicide, punishable by criminal law, and that their Deontological Code expressly forbids physicians to practise euthanasia (without qualification), is reason enough to dismiss the patient’s request as unfeasible.

None the less, in situations where staying alive causes intense suffering to the patient, which the physician cannot (or does not know how to) render tolerable, some MD´s wonder whether acceding to the patient´s wish in such extreme situations ought not to be regarded as the best procedure and, therefore, as ethically justified by the principle of beneficence.
With all due respect to particular cases which merit a sensitive, clear-sighted analysis that will uncover their deeper motivations and their unique and avoidable nature, our ethical reflection should focus mainly on the general picture of the situation. Otherwise, we would be practising the type of “pragmatic” or merely “casuistic” ethics that were formally rejected in the fundamental principles quoted above.

And the broader picture is that there exists manipulation of the physician’s (or someone else’s) will by the patient, who asks, or almost demands, to be killed by a positive act of the physician (or another person). We should bear in mind that, juridically speaking, the defining characteristic of this crime resides in the perpetrator’s will being dominated by an impulse arising from the “patient’s” condition.
The ethical judgement on this (medical) decision, resulting from manipulation, ought to be one of disapproval.

5. A patient in terminal situation, who is unconscious and, therefore, incapable of expressing his/her will. The physician (or another person), psychologically overcome by what he/she considers to be an unbearable situation for the patient, and having no treatment for it, decides to kill the patient by pharmacological or other means.
Such a (medical) decision is configured as an act of active euthanasia, and it is involuntary because the patient has not expressed his/her will. 3
Objectively, this is an unacceptable medical decision, because the physician, out of real or supposed compassion, bestows upon him/herself the right to dispose of a human life; and, from the ethical perspective on which the present analysis is based, the physician is not entitled to that right.
Similarly, a negative ethical judgement applies to a situation in which the terminal patient is conscious, does not manifest the wish to be killed, and the physician decides to kill him/her.

The possibility that the physician may make such a decision creates conditions for the manipulation and instrumentalisation of the physician’s will, by third parties who have a personal vested interest in that decision and by the prevailing political power (there are well known historical examples of the latter, some of them in this century).
Besides this real and verified risk, such a medical decision offends the ethical and deontological principles that are generally accepted in medical  practise (with the exception of Holland). [2]

6. A patient who, in normal circumstances, in full and sound conscience, has drawn instructions - known as “Testamento de Vida” (Life Testament)  -  prohibiting the application of certain treatments in situations when he/she might be unable to express his/her will, even if such situations seriously threaten his/her life.
When such a situation occurs, the physician must decide whether or not to obey that will, freely expressed by an autonomous person at an earlier time.
Here, ethical analysis is difficult [3]. Ought the physician to obey?
In the light of the principle of autonomy, it would seem that he ought to.  But can anyone be sure that such a decision, made by the person at a time of good health, would still be its genuine wish now that it is seriously ill?  If the person could be informed of its present real situation, would it not consent to a treatment which, in the past and without the present information, it has refused?
Most authorities on ethics are of the opinion that, when in doubt, and when it is not a case of futile treatments, or “heroic” treatments with little probability of success, or treatments which cause great suffering and are disproportionate to the expected benefits - when, in fact, the patient’s will coincides with the medical decision to refrain from treatment - the physician  is  not ethically obliged to comply with those previous instructions; all the more so if there is reasonable probability that the patient’s life be saved by using the appropriate therapeutic measures which the patient had refused in anticipation. This opinion takes into account, specifically, that the patient’s expressed will is neither “current” nor “informed”.

In case the physician decides to comply with the patient’s will by not initiating or by actively suspending therapeutic measures whose only effect is to prolong the process of dying - measures which the patient expressly rejected in a previous document, or before he/she became unconscious (e.g. in irreversible coma) - such a decision is ethically defensible if it is accompanied by all the measures necessary to ensure the comfort and well-being of the person in the process of dying, even if such measures may presumably, and there being no alternative, reduce the duration of the dying process.
It is illegitimate to call this decision “passive euthanasia”, for it is simply good medical practise.

7. Equally deserving of a favourable ethical judgement is the medical decision not to initiate extraordinary measures of respiratory or cardiac support when these are not medically useful, as well as the medical decision to suspend such measures as soon as brainstem death has been

8. To round off this analysis of typical cases with a final synthesis, I shall say that it is necessary, from the ethical perspective, to lay down a clear line of distinction between medical decisions representing active ways of producing the death of patients - “medical death”, as Siegler calls it - and the decisions to maintain or suspend artificial means of life support as medically appropriate, or the decision to apply every technique that might ease the pain and produce comfort and well-being in the dying patients. [3]
Ethical evaluation of these two kinds of decisions leads us to propose that physicians ought to reject the former - no physician ought ever to kill his/her patient - and actively engage in the latter - no physician ought ever to remain indifferent to a patient’s suffering until the last moment of life, so that human death, though inevitable, may be experienced with dignity by every person.

Prof. Daniel Serrão

[1] The Oxford Textbook of Palliative Medicine
D.Doyle, G.W.C.Hanks & M.MacDonald (eds.)
Oxford University Press, 1994 (845 pp.)
[2] Euthanasia and Other Medical Decisions Concerning the End of Life
P.J.van der Mass, J.M.van Delden & L.Pijnenborg
Elsevier, 1992
[3] The Physician-Assisted Suicide and Euthanasia Debate
- An Annotated Bibliography of Representative Articles
J.J.Fimes & M.D.Bacchetta
The Journal of Clinical Ethics, 5 (4): pp.329-340, 1994

1. Such a decision is punishable in Portugal with a sentence of 6 months to 3 years imprisonment if the patient is imputable, aggravated to a sentence of 2 to 8 years if the patient is not imputable. There is, thus, social condemnation, laid down as law, of such medical behaviour (cf. the Penal Code, Art.135).
2. In Portugal, this is constituted juridically as homicide at the victim’s request (Penal Code, Art.134). The physician who practises this incurs a sentence of 6 months to 3 years imprisonment.
3. Punishable, in terms of the Portuguese Penal Code (Art.133) as voluntary manslaughter, with a sentence of 1 to 5 years’ imprisonment.  Note the difficulty for the judge of having to enter the intimacy of the physicians’s moral conscience so as to ascertain to what extent the patient’s situation has “dominated” the physician’s will, leading the latter to commit a homicide.

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