RESEARCH ARTICLE End of Life Issues in Cancer Cases: Ethical Aspects

This article investigates ethical challenges cancer patients face in the end stages of life including doctors’ responsibilities, patients’ rights, unexpected desires of patients and their relatives, futile treatments, and communication with patients in end stages of life. These patients are taken care of through palliative rather than curative measures. In many cases, patients in the last days of life ask their physician to terminate their illness via euthanasia which has many ethical considerations. Proponents of such mercy killing (euthanasia) believe that if the patient desires, the physician must end the life, while opponents of this issue, consider it as an act of murder incompatible with the spirit of medical sciences. The related arguments presented in this paper and other ethical issues these patients face and possible solutions for dealing with them have been proposed. It should be mentioned that this paper is more human rational and empirical and the views of the legislator are not included, though in many cases human intellectual and empirical comments are compatible with those of the legislator.


Introduction
Sometimes dealing with patients in final stages of life is associated with complexities from ethical viewpoints that cannot easily be judged and or ruled. Intellectual and empirical or definitive ruling cannot be issued and the correct decision should be made based on the principles of medical ethics and in consultation with experts in the field. So far, doctors, philosophers, ethicists, and even many religious scholars have discussed, theorized and proposed solutions but the fact is that the variety of cases and dependency of this subject to theoretical and philosophical foundations on multiple domains along with new approaches that are created due to recent advances in medical science, cause not only the questions posed regarding such patients did not reach a definitive answer, but also every day the number and scope of the questions are increased. In this paper an attempt is made to briefly describe the current situation, the main issues for general arguments, and evidence in this field. Obviously, like any other field, enjoying practical experiences and theoretical achievements of other countries can be helpful to attain a comprehensive plan in Iran. It should be noted that some of theoretical approaches and logical arguments presented in this paper are presented solely for the purpose of presenting diverse perspectives and proposing them does not mean that they are accepted or rejected. Hancock (2006) believes that the moral behavior can be considered as a biological phenomenon and a consequence of social life. Even if ethical problems have existed since ancient times and paying attention to ethics in the treatment and care is always a focal point, thanks to advances in sciencehas shown itself more serious. Equipping hospitals' intensive care units with mechanical ventilation and the use of pacemaker devices for patients with advanced heart disease, which increase patients survival while their quality of life is not good enough, is of major ethical challenges in advanced medical centers in the world these days (Hancock, 2006).

Materials and Methods
To obtain the necessary background information, a literature review was done using numerous online search engines including MEDLINE, Web of Science, Ovid, and EBESCO.
Specific search criteria were used to research articles on the search engines. These included articles written in English, articles from the clinical trial, case report/ series, and editorial categories. The keywords entered into the "PubMed" search engine of MEDLINE included "euthanasia", "ethics in end of life care", "palliative care", and "physician assisted suicide". Similar keywords were used in other search engines. Out of the 230 articles obtained from the keywords, 63 were further investigated. Of these, only 16 were used for this review. The chosen articles specifically addressed the topics we investigated.
Various articles, scientific journals, and polls/surveys were obtained from these resources. Primary sources, including books and scientific sites, were also reviewed.

Ethical Challenges: research and treatment
Ethical challenges related to patients in final stages of life can be categorized in two parts: research and treatment. The main challenge in the field of research is whether a man has a right toward finding a cure for incurable diseases such as cancer via exposing other animal species to diverse types of cancer. Or in the case of research on cancer treatment drugs and during clinical trial procedures on healthy people and patients. What ethical considerations should be concerned?
The importance and influence of these issues persuade researchers to try new ways to experiment on other species. One method is implanting human tumors in Nude Mice. These mice due to a genetic mutation lack T cells and their weak immune system creates a susceptible ground for heterotransplant. So researchers can do initial testing in cancer field with no need for performing painful procedures in previous methods only by using the tissue samples taken from these kinds of mice. Other efforts also have been done to restore cancerous cells to normal cells and if it can be done successfully, it would be useful for all patients or researchers interested about anti-cancer drugs. The first phase of a standard clinical trial is conducted on healthy people, in some cases to protect healthy volunteers. This stage of the research process is overlooked and other steps of research are conducted on patients whose bodies have not responded to other cancer treatment drugs. So it is obvious that the main goal in current medical researches on cancer is to direct the research in a way that harm other species as little as possible. In this approach, Hancock believes that ethical philosophy in medicine should be based on bio-ethics not merely human ethics. This means that any form of life must be respected not only in human form. This view of Hancock is also accepted in view of divine cultures.
Ethical challenges associated with patients' treatment in end stages of life, especially in cancer patients, generally overlap with good death (euthanasia). The reason is that cancer often comes to a point that imposes a painful condition to the victim so much that the patient or relatives (even sometimes without the patients' will) ask the medical staff to end his life. As mentioned before, recent advances in therapy are a cause of moral complexities when faced with cancer and other incurable diseases. One example is new methods of chemotherapy allowing patients to choose between death and life within a short timeframe and sometimes with very low quality. Another example is the use of strong alkaloids such as morphine that reduce the pain and other side effects such as addiction, or respiratory system impairment and even respiratory arrest.
From another point of view, one can say that moral challenges these patients face largely depend on the relationship between a patient and his physician. For example, in the case of prostate cancer in a 60 year old man, making decision regarding the prostatectomy, chemotherapy, radiation therapy or even palliative treatment is more useful for the patient when it is performed regarding his consent and that it is possible by establishing a good relationship with the patient. Deciding on this particular case and any other cases requires ethical reasoning and thinking, familiarity with communication skills, moral principles, and consult with an expert if necessary.
In this case, and many other similar cases, there are two main sectors: Patients and their Physicians, to find appropriate solutions to ethical challenges associated with rights and duties, both patients and doctors should be considered. One cannot just do it by focusing on one and ignore another. When Hippocrates presented his famous oath, long ago, ethical challenges of treatment of cancer patients based on doctors' duties, with no attention to obligations, responsibilities and individual rights of patients, but todays along with establishing personal freedoms and respect for autonomy, patients have rights to choose treatment plan as painful curative treatment with probably low outcome or palliative care with nearly no pain. Holleb and Braun (1986) believe that the main question to be addressed is the doctors' responsibilities from the perspective of patients' individual rights. It seems that these two researchers believe that decision making for end of life is so complicated because factors such as the large number of people who are involved in the treatment process, cancer's complexities, availability of new technologies and inability to have correct answers to the following questions make it even more difficult: What is life? What is death? What is the relative value of life and death? Who benefits from them (Huang, Liu, Yu, & Wu, 2015) ? As can be seen, the true facing with ethical challenges of treatment of cancer patients requires acknowledging the crucial role of physicians in defining values. That is why Gaylin (1983) writes: "Doctors today define the values and explain ethics; they play an effective role as a social force in the lives of their patients. It is a fact and whether doctors like it or not, they are in such a position. There is nothing as medicine free from values and not existed before also. Accepting the fact indicates honesty not arrogance, and this is the first step that must be taken to redefine the role of physicians in the New World. So you can see that Gaylin (1983) did not consider the medical profession free of moral values and thus decision making should be based on research, treatment and care of cancer patients.

Medical Ethics in palliative care of cancer patients
The World Health Organization suggests, in a pamphlet entitled "Control of Cancer" published in 2007 that has mentioned various aspects of palliative care for cancer patients, the following as ethical and legal issues that must be considered in palliative care for cancer patients: *Allocate sufficient financial and human resources to palliative care *Integration of palliative and curative care to enhance quality of care *Social, personal and professional commitments and responsibilities related to the proper care of cancer patients *Considering cultural differences and different value systems, for example, considering that in given conditions is typically defined in terms of neuropathology terms. (Jacox, Carr, & Payne, 1994) In the past three decades, the view has been gradually strengthened that pain is not only a physiological sense. Pain is a human unpleasant feeling that is related to all the factors affecting the quality of life (Ferrell, Grant, Padilla, Vemuri, & Rhiner, 1991). For this reason, researchers from the fields of psychology, theology, etc. have attempted to study unexplored aspects of the suffering of cancer patients. A cancer patient is suffering because the entirety of his existence is threatened. This feeling has physical, psychological and spiritual dimensions. (Cassell, 1989) Ferrell et al (1991) have studied the effects of pain on individuals' personality. In their model to explain the relationship between pain and quality of life, four dimensions are considered: Physical health, psychological health, social health and mental health. Physical health is not limited only to sensation of pain and includes insomnia, fatigue, nausea and dysfunction of internal organs. According to Ferrell (2005) in psychological dimension it is known that chronic pains are usually associated with anxiety, depression and fear of future pains. He also explains that the pain does not happen in isolation and in most cases also affects individuals' social relations. The pain of a cancer patient affects greatly those around him and who care him and the role of patient in the family, workplace, and community. In spiritual dimension, pain is shown as a deep sense of despair and a sense of oblivion. In such circumstances, the patient's beliefs about the meaning of life sometimes are weakened, and may even cause him to think of suicide. This dimension is closely related to individuals' religious beliefs and may be shown as the despair of the mercy of his Lord in a religious man. However, sometimes cultural and traditional beliefs of the individual suggest that the pain is necessary and it makes him closer to God.
Sometimes medical care will ultimately lead to increased pain in patients. This requires an explanation. To better understand the content, current conditions should be compared with the time that medical care did not progress much. Most progress has been made in this area since 1940s. New methods of diagnosis, new surgical techniques, antibiotics, and other factors affecting facing with serious illnesses cause now a lot of people, rather than die in a short period of illness, survive and endure a chronic and long pain. Official statistics show that approximately 90 percent of cancer patients or those with other incurable diseases are in pain despite treatment or conservative actions (Jacox et al., 1994).
Dr. Eric Cassell (1982) in his classic paper titled 'nature of pain and medical purposes' published in 1982, asserted that enduring pain is a state of mind and cannot be limited to the individual's physical condition. He believes that a person feels pain when his integrity is placed at risk.

Cancer patients and euthanasia (mercy killing)
According to a study conducted by Davis and the quality of life has higher value or not, suffering is considered important and what is the view toward the end of life and its quality * A patient freedom in deciding how to treat and family awareness of the consequences of medical procedures. * Considering legal and cultural obstacles to the use of palliative care for example narcotic usage for pain control. (www.who.int/cancer/publications/cancer.../en/, Organization, & 2007Organization, & , 2007 Also in above cases noted that the divine about human is prevailing and human dignity in terms of individual and social rights is considered.
National Health and Medical Research Council in Australia has presented four moral principles in palliative care and explained the relationship between them in the following graph: Respect for patient best possible way to those suffering from chronic conditions and spending the last days of their life. Of course this must be done in such a way that justice is implemented about everyone involved in the care process.

Respect the patient
The patients' will should be considered and he is allowed to participate in decision making process about treatment or cure in such a way that everything is done according to patient consciousness, will and desire.

Justice
the demand for justice is that the patients and all those who are involved in some way in the process of care, including family and hospital staff are treated fairly and available resources are responsibly and wisely placed at their disposal.

Good care
patient changing needs and the things related to his care and treatment that he prefers should be taken seriously and his comments should be considered continuously and done until these patients stay calm in last days of their life. Under no circumstances the dignity of patients should not undermined.(www.nhmrc.gov.au/) It is seen that individual rights, authority and human dignity are considered well in all above.

Ethical issues of pain management in cancer patients
Pain means experiencing an unpleasant feeling that Higginson (2004), we know that almost three-quarters of cancer patients are over 65 years old. Older cancer patients are at greater risk of malnutrition. For this reason, older cancer patients are one of the main groups who need palliative care after a while and have to spend the last days of their lives in difficult conditions (Beck, 2001;Charles, Mulligan, & O'neill, 1999). Here the importance of having a clear plan based on clear and consistent moral principles involving cancer patients will be determined. Clinical, legal and ethical issues related to whether such persons should have been kept alive by all means or not have raised much ethical, emotional and medical arguments (Fine, 2006;Ganzini, 2006). Euthanasia, good death or mercy killing referrers to a condition that a patient is in final stages of life and his retrieval is not expected, therapies are not effective and finally its foreseeable consequence is death, which is often accompanied by much pain and suffering. In such conditions, the patient, his relatives and sometimes medical team decide to provide a comfort death for the patient by cutting his life-giving actions, or non-use of actions that help the individual to survive and/or even lethal medication prescription for the patient under general anesthesia. Their goal of this action is to save the patient from suffering and their motivation is to have mercy on the patient. One reason for the overlap of elderly cancer patients' discussion and euthanasia in medical ethics debates is the issue of looking after these patients, their life and its quantity and quality. However, in divine cultures, the legislator considers no human has the right to choose his life or death and human must consider life as a blessing in harmony with creation system and protect it as a gift of God and any self-inflicted harm or illness is not allowed. So for many reasons that are beyond the scope of this paper do not have the right to choose death as euthanasia. So the doctors did not have the same right for their patients. In contrast, thorough caring of patient even in dying stage and life preservation is the main task of doctors(B. R. Ferrell, 2006).

Euthanasia Opponents argument
In today's world opponents of euthanasia have more power and run their opinion in terms of new legislation in Europe or American states. Arguments expressed by both the opponents and proponents of euthanasia, particularly in cancer patients, can be useful in order to achieve a full and fair view of the ethical issue in palliative care area. For example, in April 2007, a group of cancer experts in North and South Carolina announced their objection to the legalization of euthanasia by issuing a statement. The statement suggests: The physician-assisted suicide is the wrong answer to the right question. The first responsibility of a doctor is not hurting the patient but this action can eradicate the trust between the doctor and patient. It appears as an act based on the patient's wishes while a physician perspicuously ignores the most basic rule of his profession i.e. life maintain and pain relief by doing this. Helping a patient to suicide is leaving the patient alone. We are well acquainted with all the problems in palliative care but we believe that instead of abandoning patients should strengthen research and education in this area. It should be noted that many patients demanding mercy killing make this decision due to anxiety, depression or fear of upcoming pains. We oppose this bill because it is a bad act that is based on the moral evil and leads to immoral medicine. (Fry-Revere & Koshy, 2007) As can be seen, opponents of mercy killing of cancer patients in America insist more on their positions by issuing statements of this kind and are not willing to easily accept arguments presented by the proponents of the act. The discussion in countries such as Iran, which has a wealthier culture and stronger religious bases, is far more serious and in near future, it will be accepted generally. Now, we should briefly refer to this important issue that if doctors and patients entirely do their duties for incurable and painful diseases, suffering of patients and the quality of life are modified in a way that the patient will prefer to live and principally it is a general and normal feeling that majority of people and even patients select life to death, this easily implies the duty of physicians to preserve the life.

Discussion
It can be said that different groups of Iranian scholars in the fields of medicine, ethics, religion and sociology should examine ethical issues related to the maintenance of cancer patients, especially mercy killing problem from different aspects by relying on their cultural beliefs and scientific knowledge and in the course do not hesitate studying the experiences of other nations and arguments presented in other spheres of civilization. As previously noted, moral issues cannot be resolved easily with the general rule but it is necessary to address every single example precisely so that what actually happens has the least possible distance with human values and our religious beliefs. Our task is to work in this field on the basis of divine comprehensive culture that is common to all human societies and all religions agree on it not based on personal opinions and preferences and as said in researches presented in this paper all experts and international organizations confirm divine culture in this case .