Discretionary Death

As a result of advances in medical technology and antibiotic therapy, the average life span in Western societies has increased significantly. Most people no longer die from infections or parasitic diseases but from protracted degenerative diseases; for this reason, dying may be a prolonged and painful process. This situation has paved the way for changes in hospital practices concerning death, where limitation of life support and even hastening of death are becoming increasingly commonplace. Consequently, a subtle but major conceptual shift has taken place regarding established notions of natural and unnatural death. Discretionary death thus defines and identifies a class of death situations that has become increasingly common and which entails neither natural death (defined as death without human intervention) nor unnatural death (defined as accident, negligence, or killing).

A New Technical–Medical Context

Modern life support technology in health care is able to uphold life functions in critically ill patients to a considerable extent and for a significant period of time. These forms of technology have been enormously successful in rescuing patients from medical crises, such as heart failure, stroke, hypothermia, traumas, and other acute life-threatening episodes and have made it possible to perform major surgical procedures.

Alongside the major benefits these technologies provide, they also lead to unintended consequences in the form of growing human and financial costs, for instance, the futile prolongation of dying processes in incurable patients. Furthermore, some of the rescued patients suffer from serious neurological deficits and/or poor quality of life. In response to these unintended consequences, the first standard guidelines for limiting life support in cardiopulmonary resuscitation and ventilation were issued in the 1970s in the United States. Later these guidelines were developed into institutionalized practice based on the principles of patient autonomy and informed consent.

Death and End-of-Life Decisions

Death preceded by decisions of limiting life support or forgoing of life-prolonging treatment are increasingly common today. (The limitation of life support is indicated by different designations such as do not resuscitate orders, allow natural death, forgo life-sustaining treatments, advanced directives, or withholding and/or withdrawing life support.) Comparative studies of end-of-life decision making in Europe and the United States indicate that the administration of drugs with the explicit intention of hastening death and decisions to limit life support without the patient's request are commonly practiced. Approximately 70#x0025; of all deaths in European intensive care units are preceded by a decision to withhold or withdraw support. Even larger figures are reported for neonates and infants in intensive care units in Europe and the United States. In several European countries one fourth of all hospital deaths are preceded by decisions to limit treatment or hasten it through palliative efforts.

Futility, Quality of Life, and Patient Autonomy

End-of-life decisions are related to several factors, including medical and social factors. The principal medical factors influencing the decision to limit or forgo life support are prognosis, condition of the patient, and assessments of the utility of treatment, that is, determinations of futility. However, considerations of whether the patient might benefit from further life support are not entirely medical as they entail judgments about the expected benefits for the patient as well as the avoidance of inflicting harm. Futility sets an upper limit for intervention, justifying turning over the process to nature, for which human agents are not responsible. In a sense, futility has developed into a pivotal normative concept that guides and supports judgment in the area of discretionary

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