Considerations about ethical and legal aspects at the end of life during the COVID-19 pandemic

The Sars-CoV-2 pandemic which has plagued the planet and in particular, Brazil, has killed more than 200,000 people so far. It has placed the discussion about some procedures to be adopted on the agenda, such as those for when a patient is approaching the end of their life, bedridden in an ICU bed, isolated in an infirmary, and is on their deathbed but remains alive with their anxieties, uncertainties, and feelings of abandonment. During the first week of January 2021, the Jornal da USP (1) published a report in which students at the boarding school of the Faculty of Medicine of the University of São Paulo, engaged as volunteers to combat COVID-19, stimulated a debate on the practices of palliative care in the undergraduate curriculum under the claim that ideally, ‘‘such care should start when a person is diagnosed with a disease that compromises their life.’’ Both issues (the right to a dignified death and the implementation of systematic teaching of palliative care in medical education) generate some pertinent reflections within the tragedy that we are all experiencing. The first of these reflections is about how to deal with the end of a patient’s life—bringing up primordial issues that are often covered up, such as orthothanasia, dysthanasia, and euthanasia—both ethically and legally. The second issue that requires reflection concerns the point raised by undergraduate medical students about the opportunity for initial palliative care as well as the inclusion of this discipline in medical curriculum. Regarding the first topic, some observations must be made a priori. William Frankena (2), a bioethicist at the University of Michigan, gives us the example of the philosopher Socrates (in one of Plato’s dialogs – ‘‘Críton’’) when he was faced with the opportunity to escape from prison with the help of friends and save himself and his family. ‘‘We must not allow ourselves to be dominated by emotions, but to follow the best logical and moral reasoning. We must not get carried away by what most people believe is right, because they may be mistaken; we must reason for ourselves. Finally, we must not do anything that is morally wrong.’’ And, by obvious deduction, we can say, ‘‘We must do what is morally right.’’ Starting from the Socratic premise that ‘‘we must not do the morally wrong,’’ in relation to the ethical issues about the need to have a dignified death, Levine (3) points out that ‘‘for decades, we have been trying to put this ideal into practice. Undoubtedly, palliative care currently makes a difference for some people, even though death is still accompanied by unwanted and ineffective interventions, excruciating pain and suffering, and loss of personal dignity and autonomy.’’ The author also recalls that lawyers have recommended that people prepare their so-called ‘‘vital wills’’ or ‘‘advance will guidelines’’ as a precaution against useless and potentially painful treatments. However, he warns that there are criticisms about the ‘‘authenticity’’ of these documents (since the person who signed it is no longer the same person at the present moment of a terminal illness), not to mention the legal issue surrounding this whole problem. However, this is a long and separate discussion that will not be our topic for now. It is enough to say that the living will or advance will guidelines are now fully accepted and recommended by the Federal Council of Medicine. From this point of view, it is our impression that the intersection of ethics, bioethics, and legal issues is not new. As Hall and King (4) state, ‘‘in the 1970s and 1980s legal disputes over the right to death dominated discussions, culminating in the 1990s with the decisions of the American Supreme Court in the Cruzan (forced feeding) and Glucksberg (assisted suicide) cases.’’ It is precisely the legal issue, in our opinion, that should require more accurate attention from doctors: what is morally correct is not always legal, or protected by law. This article aims to present some ethical and medico-legal aspects that involve the end of life and to discuss the pertinence of expanding the teaching of palliative care in medical education, as well as to discuss the ideal opportunity to start this practice when the patient faces a real threat to life.