FEU Public Intellectual Lecture Series | Dr. Maria Fidelis Manalo

Summary

In this enlightening FEU Public Intellectual Lecture Series, Dr. Maria Fidelis Manalo, an expert in palliative care and bioethics, shares vital insights about ethical dilemmas in medical practice. Dr. Manalo discusses the principles of bioethics—autonomy, justice, beneficence, and non-maleficence—and highlights the importance of understanding these concepts in both beginning-of-life and end-of-life scenarios. The talk emphasizes that life is both valuable and sacred, illustrating the complexities of medical decisions involving abortion, euthanasia, and assisted suicide, along with fostering ethical practices among healthcare professionals.

Highlights

• Dr. Manalo, a palliative care expert, delves into complex ethical issues in medicine 📚.
• The discussion touches on abortion, euthanasia, and assisted suicide, offering a comprehensive view of bioethical challenges 🚑.
• Key bioethics principles: autonomy, justice, beneficence, and non-maleficence are explained in a meaningful context 🌟.
• Doctors face the ethical challenge of balancing life, dignity, and medical possibilities in patient care 🏥.

Key Takeaways

• Bioethics explores ethical questions in life-and-death medical scenarios, encouraging informed decision-making 🤔.
• Understanding bioethics principles like autonomy, justice, beneficence, and non-maleficence is crucial for everyone ⚖️.
• Life is sacred and should be treated with respect, with decisions made thoughtfully considering ethical principles 🌿.
• Being informed and consulting experts is essential for resolving ethical dilemmas in healthcare 🔍.

Overview

Dr. Maria Fidelis Manalo, a notable figure in the realm of palliative care and bioethics, delivers an insightful lecture focusing on the ethical intricacies faced in medical practice. This session underlines the importance of bioethical principles, such as autonomy, justice, beneficence, and non-maleficence, which guide medical professionals when confronting critical life and death decisions.

The lecture navigates through sensitive topics like abortion, euthanasia, and assisted suicide, presenting a balanced narrative that respects life's sanctity while acknowledging the complexities doctors face. Dr. Manalo emphasizes the significance of viewing life as sacred, urging both the public and healthcare professionals to thoughtfully deliberate ethical principles before making medical decisions.

Through engaging stories and practical advice, Dr. Manalo invites both medical students and the general audience to learn from real-world scenarios, advocating for the informed and reflective application of bioethical standards. The lecture is designed to empower individuals to act with integrity and moral clarity in the field of healthcare.

Chapters

• 00:00 - 03:00: Introduction to Bioethics The chapter begins with a welcoming note from Rita Kusho from the Political Science department, introducing the topic of Bioethics. The lecture is part of the Far Eastern University public intellectual lecture series.
• 03:00 - 04:00: Principles of Bioethics This chapter delves into the realm of bioethics, a particularly debated segment within applied ethics. It addresses contentious issues such as abortion, euthanasia, cloning, and stem cell research. The discussion is enriched by insights from a guest who is a distinguished doctor, researcher, and professor specializing in palliative care. Currently, this expert heads the supportive and palliative care section at the medical city, providing a wealth of knowledge on these sensitive subjects.
• 04:00 - 07:00: Role of Natural Moral Law This chapter discusses the role of natural moral law in the context of medical ethics. Dr. Lisa C. Manalo, an assistant professor and a member of the hospital ethics committee, shares her insights on the subject. She is also an active consultant and part of the ethics committee at FEU Niconorius Medical Foundation's Medical Center and Institute of Medicine. The chapter explores how natural moral law impacts decision-making in medical practice and ethical considerations within hospital settings.
• 07:00 - 12:00: Patients' Rights and Ethical Dilemmas The chapter discusses the importance of bioethics, a subset of ethics that deals with the dilemmas in life sciences. It emphasizes the necessity for individuals, not just professionals, to be aware of bioethics. The conversation highlights the nature of ethical decision-making in healthcare and the challenge of determining right or wrong actions.
• 12:00 - 17:00: Life and Death Ethics This chapter discusses the field of bioethics, focusing on the application of ethical principles from the beginning to the end of life, including natural death. It emphasizes the importance for individuals, especially students, to develop principles that guide decision-making in these contexts.
• 17:00 - 21:00: Beginning of Life Ethics The chapter "Beginning of Life Ethics" focuses on the critical and sensitive nature of bioethics, emphasizing the thin line between life-saving and life-ending decisions. It stresses the importance of healthcare professionals being deeply grounded not only in medical knowledge and skills but also in the ethical considerations that govern life and death situations. This underscores the responsibility in medical ethics, where errors can have dire consequences such as untimely patient deaths due to negligence.
• 21:00 - 30:00: Euthanasia and End of Life Care This chapter deals with important ethical issues surrounding euthanasia and end-of-life care. It emphasizes the need for guiding principles in making ethical decisions. A strong point made in the chapter is the importance of having a standard to determine what is considered ethically right or wrong. The chapter discusses bioethics in the context of real-life situations, highlighting the necessity for careful consideration and adherence to established ethical standards when faced with difficult decisions regarding end-of-life care.
• 30:00 - 37:00: Physician-Assisted Suicide The chapter delves into the concept of natural moral law, a standard that guides individuals in discerning what is morally right and wrong. This law is considered 'natural' as it aligns with an innate human inclination to choose good over evil. The discussion sets the stage for examining ethical dilemmas, focusing particularly on the context of physician-assisted suicide.
• 37:00 - 42:00: Patient Autonomy and Ethical Decisions The chapter titled 'Patient Autonomy and Ethical Decisions' discusses the complexities surrounding ethical decision-making in medical practice, emphasizing that decisions are not always black and white. It highlights the importance of understanding natural moral law, which can guide healthcare professionals in their interactions with patients, particularly in maintaining truthfulness.
• 42:00 - 48:00: Principles of Ethical Decision-Making This chapter explores the concept of a 'good death' from both medical and patient perspectives. While healthcare professionals might focus on pain and symptom management, a study from Pittsburgh reveals that patients and their families often define a good death as being at peace with God. This highlights the importance of understanding and respecting diverse values and beliefs in ethical decision-making processes.
• 48:00 - 58:00: Case Studies in Palliative Care The chapter 'Case Studies in Palliative Care' delves into the disparity between patient expectations and medical practices in palliative care settings. The doctors focus on providing good pain and symptom control, while patients often seek more holistic and personal approaches to their care, including the importance of truth-telling. The emphasis is on ensuring that patients are aware of their condition to achieve closure.
• 58:00 - 80:00: Advice for Students in Bioethics This chapter delves into the cultural nuances and ethical dilemmas faced by medical professionals, particularly in the context of Filipino culture. It addresses the sensitive issue of communicating with patients who have terminal diagnoses and the reluctance in certain cultures to convey the truth to avoid causing distress to patients. The text emphasizes the implications of withholding information, such as the potential for increased anxiety and the impact on a patient's end-of-life decisions.
• 80:00 - 87:00: Conclusion and Recap In this chapter, the discussion centers on the ethical dilemmas faced by medical professionals, particularly the conflict between telling the truth to patients and respecting the wishes of their families. There is emphasis on the importance of honesty, especially when patients confront doctors with direct questions about their prognosis. The chapter underscores the challenge of balancing transparency with compassion, highlighting the frequent moral complexities encountered in medical practice.
• 87:00 - 93:00: Closing Remarks and Acknowledgements The chapter discusses the complexities and ethical considerations in the medical field, particularly when dealing with emotional and physically ill patients. It raises questions about the rights of patients who are not lucid or cannot make decisions for themselves, and the processes needed to ensure ethical decision-making.

FEU Public Intellectual Lecture Series | Dr. Maria Fidelis Manalo Transcription

• 00:00 - 00:30 [Music] good day welcome to the far eastern university public intellectual lecture series my name is rita kusho and i am from the political science department today we are going to discuss one of the most interesting
• 00:30 - 01:00 if not controversial areas in the field of applied ethics so when we talk of issues like abortion euthanasia cloning stem cell research we're actually going into a field called bioethics and today we are very privileged to have with us an esteemed doctor a researcher and a professor in this field our guest is a palliative care specialist who is currently the head of the supportive and palliative care section of the medical city
• 01:00 - 01:30 where she is also a member of the hospital ethics committee she is also an assistant professor a regular active consultant and member of the ethics committee of feu's niconorius medical foundation's medical center and institute of medicine she's none other than dr lisa c manalo good day dr manalo good day erita and everyone thank you very much for inviting me to the feu intellectual lecture series and thank you doc also for accommodating us
• 01:30 - 02:00 despite your very busy schedule you're most welcome and i'm and be glad to share whatever knowledge i have with our students here in feu thank you doc so let's start with the basics though what is bioethics and why is it important for us ordinary citizens to know about this well obviously the bigger picture would be ethics and when people talk about ethics ultimately one has to make a decision as to this particular action would be right or
• 02:00 - 02:30 wrong so when you talk about bioethics it's the application of ethical principles it matters pertaining to practically the beginning of life up to the end of life which is natural death and in between for that matter so um and therefore the the student and all all people in general should be able to come up with certain principles that will guide him to make the right decision so i suppose what i'm clarifying here is
• 02:30 - 03:00 that especially in the field of bioethics you're dealing with life and death there's practically no room for error either you save a patient's life or because of negligence on your part you actually led to the untimely death of your patient no so that's why they have to be well grounded not only in the knowledge of medicine in the art of medicine but in the ethical issues governing life in there oh that's that's very interesting because i think all of us will have to go through
• 03:00 - 03:30 a case in our lives where we have to deal with bioethics issues correct all right so when when people are in in that situation or in they have to they have to handle or they're faced with a case on bioethics what are the principles that should guide them in making ethical decisions in making ethical decisions well in the first place one of the things is for you to know if you're on the right you have to have a standard right so and therefore as far as ethics is
• 03:30 - 04:00 concerned the standard that we actually follow is what we call natural moral law moral meaning what guides man in choosing what is right and what is wrong but it's it's natural in the sense that it comes naturally to a human being to to choose what is good rather than to choose what is evil so knowing natural moral law therefore then when a person is faced with some ethical dilemma and many times the ethical dilemma is
• 04:00 - 04:30 not actually pure black and white no so there's a lot of reason in between if she's knowledgeable about the teachings of natural moral law then you might say she will be guided along that path what what am i talking about something so simple as being truthful for example we face that all the time in when we're faced with patients no i am a palliative care doctor and therefore i take care of dying patients so i always tell my students you only die once
• 04:30 - 05:00 so i suppose all of us would want a good death right and we actually did a study um in pgh about this and when we ask patients what you consider a good death would you believe their answer was to be at peace with god so that was wow amazing that's what they meant by a good death champion as doctors we thought ah good pain control good symptom control etc etc but for them it's about a good death is being at peace with god when we ask the family members taking care of them the answer is the same so it's like wow
• 05:00 - 05:30 really amazing but when we asked the doctors would you believe what the answer was something very medical like good pain control good symptom control etc etc so then i realized that that's the reason why what the patients want and what the doctors give them is not one in the same so as i was saying as far as truth telling is concerned it's my personal advocacy to make sure that everybody who dies knows that he's dying because there's such a thing as closure
• 05:30 - 06:00 there might be some things that i want to finish in my life i want to resolve in my life before i go right but especially in the philippine culture they always think that when you tell the patient that she's near death that she's actually her time is limited then they will start worrying about the patient becoming depressed the patient not eating anymore hastening death in the process and therefore they would actually tell the doctors to keep the truth from the patient
• 06:00 - 06:30 that's one ethical dilemma because because we should tell the truth to the patient because it's the patient's life and death but the family tells us no and sometimes they would then what i would even ask them uh what if they really asked me doctor how much time do i have i suppose you don't expect me to lie because there's such thing as maybe i will not tell the whole truth now but on the other hand i cannot lie that's deception so does just a little of the ethical dilemma that we face day to day in our
• 06:30 - 07:00 practice your field is very you know it's very difficult in the sense that you are dealing with people who are very emotional and who are also very physically ill at the same time and i wonder um what are the rights of the patients especially if there are cases when the patients are no longer lucid if they cannot make decisions for themselves what are the processes that you have to go through in order to arrive at something that is ethical of course the
• 07:00 - 07:30 the most basic fundamental right of all is the right to life okay but on the other hand we know that we won't be alive forever right meaning uh death is as natural as living you know all of us will die eventually but uh aside from the right to life also is the right to human dignity meaning it's not just a matter of keeping me alive but i have to have the quality of life in such a way that i will be able for example to interact with
• 07:30 - 08:00 other people to be able to carry on my usual duties and responsibilities no say it's not just a matter of keeping people alive on ventilators i mean until you don't even know when like so because artificially we can keep them alive for months if not years and it brings with it a lot of pain and suffering not only to the patient but to the family taking care of them no so so those are some of the things that we encounter actually in in our practice in at the
• 08:00 - 08:30 end of life and there are also issues you've mentioned earlier about beginning of life correct so it's actually the expanse of human life correct and what are the usual dilemmas that people have to go through or people have to resolve along with their doctors as far as the beginning of life is concerned well that very question when does life begin okay so you might say as far as medical students are concerned we know our biology embryology very well we were taught in medical school our
• 08:30 - 09:00 medical textbooks tell us that life begins at conception when the egg cell and the sperm cell meets that's already a two cell stage that's already a fertilized egg the chromosomal makeup of the person is already completed 46 chromosomes which dictates that you are a human being so therefore even at that microscopic stage in the person's development it's already a human being unfortunately through the years especially with the advent of the sexual revolution
• 09:00 - 09:30 um there was a lot of free love going on and therefore quote unquote and planned unwanted pregnancy they wanted to justify the fact that um i have to get rid of this baby so therefore to somehow pacify their conscience they had to redefine the beginning of life so instead of of following what we've always known in biology in medicine that life begins at conception they sort of moved it up
• 09:30 - 10:00 later on in the in the stage of a person's development and they set it at implantation which biologically is already at the seventh to tenth day of life so one week all the young baby inside the mother so of course nobody would know about it maybe the pregnancy test will not yet be positive at that point in time but that doesn't stop the fact that the pregnancy has occurred and you have a human being there developing in your womb so one of the things that um
• 10:00 - 10:30 that is you might say debatable even up to now is the practice for example of artificial contraception no as opposed to natural family planning which is what is always been recommended by the catholic church for example no so as you know the rh bill was debated on for practically 10 if not 13 years not because there were really two camps fighting on this issue not about pro-life and pro-choice but
• 10:30 - 11:00 the pro-life would always say the antonym of pro-life is actually pro-death there's no such thing as a pro-choice because anybody in her right mind would always choose life over death but i think the advocates of pro-choice just to look at it from another perspective would say that usually women make certain choices because let's say they got pregnant because of let's say rape correct or they got pregnant and there's a threat to their physical condition to their health
• 11:00 - 11:30 yes what would normally be the process that doctors will have to go through in order to advise women who go through such as through such a case so i began by saying that one of the fundamental human right is the right to life right so whenever you have a pregnancy you're actually dealing with two lives two human beings not just the life of the mother but also the life of the unborn and actually the tricky thing here is of course you might say the mother
• 11:30 - 12:00 in principle is already grown up an adult who's able to make choices whose intellectual function is already mature whereas the fetus the unborn child is actually still in the process of development physical and mental development and therefore you might say is totally dependent on the mother for its nutrition even for its oxygen and for its growth
• 12:00 - 12:30 in general so therefore um we always say that the fetus is actually innocent harmless and defenseless now so normally you might say in the right scheme of things the strong one should be protecting the weak ones because precisely they are unable to defend themselves so when you talk about um women's lib and saying that it's my life it's my
• 12:30 - 13:00 choice it's my body of course we very well say that's correct but being pregnant you can no longer say it's just your body because inside your body is a developing fetus right so you might say um where your your right end is where the other right begins so the limitation there is yes you you are free to do with whatever you want with your life
• 13:00 - 13:30 but unfortunately there is another person's life who is entirely dependent on you and the way i always teach it to my medical students would be if you watch um animal world in cable tv what you would usually say would be for example a mother cat taking care of the pussycats right uh like a dog taking care of the puppies right and the moment you touch the pussycat the kittens and you play with them or the doggy like that knuckle the the mother cat or
• 13:30 - 14:00 the mother dog will really bite your hand for for even touching the kittens and the puppies right so they think that their puppies or their kittens lives are in danger and therefore you're the aggressor you're the predator and that's why we always say we are supposedly the wisest of the animal kingdom man and therefore if in the lower forms in the animal kingdom the parents
• 14:00 - 14:30 protect the young because the young is defenseless and innocent and harmless then there is really a big question in our mind how come the wisest of creatures animal creatures doesn't seem to follow that natural moral law of the strong defending the weak okay so but what if there are health risks correct so you were saying rape and then um health risk okay so for example in the case of rape obviously the woman has been victimized
• 14:30 - 15:00 but and she got pregnant in the process right so that's very very unfortunate but in in as much that she is a victim the child is equally a victim right so when she considers abortion to get rid of that unwanted unplanned pregnancy ultimately you might say the one who would suffer the death penalty is the innocent harmless and defenseless child who is
• 15:00 - 15:30 the victim like she is the one who should receive the capital punishment is actually the rapist so it's a lie when you a doctor proposes abortion to a person who has been raped in fact you will double her trauma she suffered the trauma of rape now she will suffer the trauma of abortion because there are a lot of studies that say that no matter how brave a front a woman puts up she will never ever be the same again after an abortion
• 15:30 - 16:00 i have personally counseled women who have gone through an abortion exactly in this condition she was in in subic and she was raped she was still an adolescent and she was raped and of course the rapist was telling her if you tell anyone i'm going to kill you so she didn't tell anyone that she has been raped and she actually got pregnant and she had an abortion so um move forward to many years until i
• 16:00 - 16:30 actually saw her maybe 10 years have passed and she's relatively successful she had made a name for herself and she came to me complaining of abdominal pain and um some dermatologic complaints she felt itchy all over so and all the tests that we ran were normal and then i so i had to relate to her that you know uh all your tests are normal there's really nothing wrong that inside you that could explain your symptoms to to say that you how come
• 16:30 - 17:00 you're in pain and then how come you're itchy until i actually started counseling and that's when she revealed to me the fact that she had an abortion and then she said that the reason why she always felt pain here was the pain of losing the child and the reason why she was always itchy was because she felt so unclean about having been raped and about having gone through an abortion there's a psychological trauma definitely nobody goes to an abortion unscathed
• 17:00 - 17:30 you'll always suffer from it physically mentally emotionally if not actually spiritually you'll later on maybe they'll suffer from extreme guilt most of them go through major depression so that's why they we always say it's a lie to assure women that abortion is pro-women no it destroys their lives they are never the same again in the case of a medical condition for example medicine has advanced to such an
• 17:30 - 18:00 extent that we have all the specialists you need to make sure that you go through pregnancy successfully so there's a doctor who has specialized in high-risk pregnancy and there's another doctor who has specialized in high-risk neonatology meaning newborn babies who are at risk of dying because of their their two preterm for example so between those two specialists more and more we are able to save lives so there's no need to coat uncoat kill
• 18:00 - 18:30 the baby to save the life of the child because no matter how you code it abortion is none other than killing an innocent different defenseless and harmless child by the mother that's the saddest thing the mother any good mother would give her life for her child a woman who goes through abortion kills her own child all right that's a very powerful statement uh doc no but i think the same issues arise when
• 18:30 - 19:00 we talk of the end of life uh care no because i i've read that in the united states for instance and in other uh western european countries they have already legalized euthanasia and there's a new term which is called assisted suicide can you please elaborate on that because i believe that that's also part of the topics that you discuss in bioethics so the way of course they would say euthanasia is none other than mercy killing at least they are clear about it you're killing someone
• 19:00 - 19:30 and usually most of the patients who ask for euthanasia are suffering from a chronic or terminal illness that is causing them a lot of suffering sometimes not just physical but mental emotional and you might even say what we call existential distress they always ask themselves why me what have i done i've always been good so how come i'm suffering like this so all those are the the way they manifest their hopelessness and helplessness now so euthanasia as the proponents would
• 19:30 - 20:00 describe it would be to relieve the suffering of people who are well in these conditions not that they are totally badly then there's no hope for a cure so but ultimately you might say euthanasia is none other than eliminating the sufferer to eliminate the suffering so in that's what we do in palliative care we're going to eliminate your suffering without eliminating the sufferer
• 20:00 - 20:30 in other words i don't have to kill you to make sure you're pain-free right and you might say that's why the popes have always said and they're really encouraging that more doctors pursued the specialization of palliative care because with the advent of palliative care the requests for euthanasia have drastically gone down because ultimately you ask any sane person would you want to live in fact our patients beg us
• 20:30 - 21:00 dog do everything possible to save my life so for anybody who would ask you don't kill me something is gravely wrong there and then you say why do you want to end your life and then they would say because i'm suffering so much dog then i would say what if i relieve your suffering you would just still want to end your life and they would say of course not dog i have to i have to be keeping myself alive and healthy for the sake of my family so they have their goals to keep in mind still so there so and physician-assisted
• 21:00 - 21:30 suicide is you might say very evil because you might say to be a doctor you have sworn by the oath of hippocrates to always um respect your patient to save their lives no because they have entrusted their lives to you with physician-assisted suicide it's the patient who will kill herself right but you are the doctor who prescribed the medications with which she will kill herself so so
• 21:30 - 22:00 that's what you mean by physicist physician assisted suicide so they will not they have access to those medications if you'd not you did not make the prescription for them so in your case bo there was no request you're a palliative care doctor so have you encountered any any patient who have requested for yes i always remember them they are very few but each encounter is something that you consider lengthily and even pray about i
• 22:00 - 22:30 i would distinctly recall that incident in our during our training in pgh where there was an old man looking for me old because he looked old but in reality i suppose he's not that old except that he was he was um an indigenous person and i suppose really they were having such a hard time making making ends meet no so so he came to me and then and he said
• 22:30 - 23:00 would you mind giving my mother an injection her mother was under her his mother was under our care we took care of her for a long period of time we practically pulled her out of that door but she was a mechanical ventilator but she was fully awake and able to to communicate to us of course by hand science and by writing but she needed a mechanical ventilator to be able to breathe so and but we were discharging already because she's been in pgh for a month already and
• 23:00 - 23:30 unfortunately in government hospitals you always need the bed for to make room for for another very sick patient so it's time to send her home and then we were really arranging i'm going to bring her home in that in the pj champions and then there and then all of a sudden the son came to me and said doc would you mind injecting my mother so it's like what are we supposed to inject her with so and then he he started crying
• 23:30 - 24:00 then doc please inject my mother and then i said uh let me get this clear you want me to inject something to your mother what is it exactly that you want me to inject to your mother so bottom line he started crying he couldn't cry and he couldn't tell me anymore he started sobbing well in the end he was asking for euthanasia for the mom and then i said actually even in western countries where euthanasia is legal the patient had to know that that
• 24:00 - 24:30 euthanasia will be performed in her and she's asking for euthanasia you cannot just come over and inject a person without her full knowledge and full consent about it so it's not even euthanasia that's homicide at the first degree right so by her own doctors right so and then until he explained to me the whole situation that they actually live by the relays they don't even have a home they don't have electricity their house
• 24:30 - 25:00 that the nurses station in pgh is bigger than their house there's no flooring everything is soil and the question is where will you attach the ventilator and the ventilator cost 500 pesos a day to keep it going so and and only one person is earning and they're not even earning minimum wage so how much is the minimum wage less than 500 pesos so how will they eat so bottom line is like it's not just a problem for the patient but for the entire family
• 25:00 - 25:30 then that that's when it began to sink on me that oh my goodness why didn't we consider this in the care for this particular patient precisely because for example if a patient's prognosis is very poor and the outcome is not very good there's such a thing actually is allowing natural death we need not have employed all those aggressive means of life support that entailed a lot of expense on the part of the family and now that the patient is alive and
• 25:30 - 26:00 kicking then we're going to kill her that is unethical there is nothing unethical about a terminally ill patient dying a natural death as long as we keep them as comfortable and pain-free as possible but you don't kill a living human being who's not at that door so that's what euthanasia is all about so rarely we encounter them and it's a matter of not judging them you want to commit a crime and you want
• 26:00 - 26:30 me to to be part of that crime no we cannot be judgmental each person has their story to tell and usually it's a sub story even i've heard of the term pulling the plug correct yeah and and i would like you doctor please elaborate on that because i think for most families you can afford this life support system they are very hesitant in pulling the plug correct so when should the plug be pulled away from the patient who is already dying okay so normally if a patient's
• 26:30 - 27:00 condition is such that there she's having a difficult time breathing on her own then that's when we put her we call it intubation we put a tube here in her mouth that tube goes all the way here and then so that it enters the lung and then artificially oxygen will be blown in into her lungs by the machine so that's mechanical ventilation no so um now usually if the condition is just acute
• 27:00 - 27:30 like a pneumonia you have stage four cancer but at the same time you have a pneumonia something acute you didn't have pneumonia before now you have pneumonia it's an infectious disease so normally we have a whole range of antibiotics that we can use on the patient so you might say after seven days of treatment 14 days of treatment the pneumonia will be cured already because it's something acute and reversible then logically we should be able to take out the tube and remove the mechanical ventilator so we call that natural weaning from the
• 27:30 - 28:00 mechanical ventilator unfortunately many things happen in the course of the illness of the patient and there are some cases where the patient will not be able to breathe without the mechanical ventilation so after two weeks normally we shift from a tube here down their mouth and create a hole here in their trachea we call that the tracheostomy so the mechanical ventilator is attached to the trachea well the advantage of that is now the patient's mouth is free so she can talk
• 28:00 - 28:30 and she can even swallow and and through food naturally because there's nothing here anymore but of course patients are so scared to hear that they have a hole here so it scares them no end no so so as far as pulling the plug is concerned you might say if the doctor has been taking care of this patient for a long period of time and actually knew that the patient is really terminally ill and dying they actually discuss what we call
• 28:30 - 29:00 advanced directives and say that no matter what we do your your disease has progressed to such a point that we will not be able to cure you anymore and no matter what happens it's going to end up in that and therefore if you reach this point that you're having such a difficult time breathing instead of artificially making you breathe we're just going to allow you to pass on as naturally as possible we're going to give you oxygen by face mask no intubation nothing
• 29:00 - 29:30 invasive entering through your throat no and then we're just going to give you medications to make sure that you just sleep you're pain-free and you're going to pass on surrounded by your loved ones and they can pray around you it will call the priests to also give you spiritual care and that's how we do it in palliative care so what happens is in some institutions where there's no palliative care patients enter the emergency room they are not asked about their end of life preferences they just intubate the patient without seeking their informed
• 29:30 - 30:00 consent about it they are not able to remove it because really the patient is terminal and later on they tell the family members ah she's not going to get any better she's dying let's pull the plug it creates a lot of ethical dilemma to the family because it's like oh my god you meant to say i'm going to be the one to kill my own mom or my own dad exactly but in reality if and when we actually have to stop artificial respiration since it's a medical procedure we were
• 30:00 - 30:30 the ones who inserted that tube and attach it to the mechanical ventilator in principle it should be a doctor who will remove the tube and remove the mechanical ventilator we don't even ask family members to pull the plug that's so traumatic to family members so you're they're going to remember the end of life of their parents for example in in such a traumatic manner so and therefore in these particular cases they're not actually performing euthanasia if you're talking about a terminally ill
• 30:30 - 31:00 dying patient you're actually what we call allowing natural death because you just delay death artificially so it's just the machine keeping the person alive on their own they cannot survive anymore yes yes but but but there's really as long as that's clear that we're not killing anyone we're just accepting the fact that we can no longer prevent them from dying and we're just allowing the natural process of death to happen then it's ethical and there should be no
• 31:00 - 31:30 trauma or or even punks of conscience on the part of the doctors and on the part of the family but there's a lot of misperception about the whole process now i realize that it's very difficult to become a doctor because you have to make all of this ethical decisions about your about your pa your patients correct and i'm wondering if there are certain principles that you have to abide by uh so that you you are sure that you are really making ethical decisions and helping the patients and their families to make
• 31:30 - 32:00 ethical decisions as well correct so the foundation of everything will still be the respect for human life and human dignity if that is clear that the person in front of me is a person not just a patient because patient is looking at her from a sick perspective right but a person with rights the right to life no the right to good life good quality of life then the four ethical principles that we follow in in by ethics would would come in no so the first would be what we call
• 32:00 - 32:30 beneficence these are latin terms english but derived from latin bene meaning good sense came from a verb called facture in other words translated into english that means do good okay so how do you know you're doing good because you're respecting the life of the patient you're respecting the human dignity of the patient then non-maleficence no non no and then male is evil so factually again so in english it simply means do no evil or do no harm
• 32:30 - 33:00 do not burden your patients with futile risky procedures painful procedures even so do good avoid harm that's beneficence and non-maleficent so that's those are the first two ethical principles and in fact it's the highest no always going back to respect for life and human dignity no then after that comes the principle of autonomy auto meaning self right the person's right to self determination i can only determine for myself what is
• 33:00 - 33:30 best for me if in the first place the doctors disclosed everything if we are hiding the truth from you that's why at the beginning of this discussion i was highlighting the need for truth telling on the part of doctors absolute truthfulness not necessarily um telling the truth at once but gradually in the doses the patient can accept no then with truthfulness now the patient knows the pros and cons the benefits and the burdens the risk
• 33:30 - 34:00 even the cost they will now come into an informed decision and choose for themselves i want this i don't want this and there's no right and wrong it's a matter of values and preferences and many times even their love and concern for their loved ones come into the picture no because of course cost is a major determinant in the philippine setting and lastly the principle of justice no giving every wonder jew so meaning uh fear no you equally distribute the
• 34:00 - 34:30 benefits you equally distribute the burden because unfortunately in the setting of third world sometimes it's actually the poor the uneducated the the ones who are marginalized those in the peripheries get most of the burden without getting the benefits so so so in other words if you're practicing in a government hospital for example even if they have no scent in their pocket you still will treat them as if you're going to treat the most the richest person in the philippines for
• 34:30 - 35:00 example so it's not like you're going to give this kind of care to the rich person and then uh any kind of care to a poor person no so of course but the thing is since everything is out of pocket in the philippines it's not actually unethical if a rich person can afford a ventilator and a poor person cannot afford a ventilator it's not unethical not to even attach them to a ventilator because because we cannot impoverish the
• 35:00 - 35:30 family as well so so even that is part of the equation it's not the most important but you have to factor it into the equation in the decision making whether to subject your patients to what we call ordinary means or extraordinary means of life support the most the expensive burdensome high-tech procedures and equipments fall under extraordinary means disproportionate means of life support whereas the ordinary means of life
• 35:30 - 36:00 support it's simply food and water yeah the compassionate care for the patient so those are the ordinary means of life support you've been in palliative care for quite some time doc right yes and i would like to know are there memorable uh cases that you have handled that really sort of burdened you as a doctor because you have to really come up with really ethical issues can you share with our students this dilemmas that you have gone through as a doctor in palliative
• 36:00 - 36:30 care well aside from the because usually the request from euthanasia by definition should come from the patient and i can recall because it was a colleague that would declare whom we took care of he was a practicing doctor in the provinces and he was suffering from lung cancer and then so he knew his condition as a doctor he knows the odds you might say so but since he came in breathless
• 36:30 - 37:00 severely breathless at the emergency room they they automatically intubated him and attach him to a mechanical ventilator but obviously he's not going to get any better and he knows it and of course to be hooked a mechanical ventilator is no joke i mean whether you like it or not air will be blown into your lungs and you have to breathe simultaneously with the ventilator or else you feel like you're going to drown all the more you all the more you can you feel like you cannot breathe so you have to
• 37:00 - 37:30 practice breathing with the machine you might say so so it brings with it suffering also so and he knows that he will not be able to speak anymore he will not be able to eat naturally he will not be able to communicate with his family so he's asking that we remove the mechanical ventilator and of course since he was very lucid we have to explain to him the pros and cons and what's going to happen if we remove the mechanical ventilator bottom line is he's going to die no maybe not immediately after the
• 37:30 - 38:00 removal of the ventilator but maybe a few hours if not a few days later he'll be lucky if he'll be alive a week later and so he knows and there's really nothing wrong with removing the mechanical ventilator in a patient with very poor prognosis who is able to decide for himself that this is not the kind of life i want for myself this is where the autonomy is coming in but only because he was dying we would not remove the ventilator if he were not dying no that's that's out of the question no
• 38:00 - 38:30 so but it was going to be christmas as in i think the next day was going to be christmas so of course the wife was crying like anything the children were crying like anything doctor he really wants to go and tomorrow will be christmas so i had to talk to the patient again doctor you know the your wife um it's so heartbreaking for them to make this decision that you want to to go already and it's going to be christmas tomorrow like that can we wait another 24 hours
• 38:30 - 39:00 he's not going to get any better there's no point telling him now maybe tomorrow will be another day that then he'll be better no and then he said doctor i'm ready i have made my peace with god i have gone for my confession in the last sacraments and i want to celebrate christmas in heaven so he's like so what how are you going to answer anybody like that right so and then so we were all crying like anything of course i have to appear brave
• 39:00 - 39:30 and very very composed in front of him like that no but but actually i found him very very brave and he actually had to sedate him to make the end of life very comfortable for him but sedate in such a way that he will wake up when you call his name and and you tap him like that doctor how are you like that he will say okay like that no so and he eventually um died peacefully surrounded by his family they were all praying around him a few
• 39:30 - 40:00 hours later it was memorable not because it was unethical but because um it was a very brave decision on his part and a very rape decision on the part of his family members to support him in that because unfortunately the patients could be quite clear about their end of life preferences when the patient is no longer able to speak up for himself and to insist that this is what i want the family would overturn his wishes and that is unethical
• 40:00 - 40:30 because it's the patient's right by by autonomy as long as he's fully competent his full possession of his mental faculties to decide for himself what is right and wrong as long as the doctors are very very clear about everything like cases do not resuscitate correct so if the patient is already wanting do not resuscitate and then when he's near coma or comatose the family wants all aggressive measures in reality we have all the right to
• 40:30 - 41:00 dismiss the family's wishes unfortunately we are always threatened they can sue us so this is when ethical and legal goes into battle because we're not doing anything unethical but they could sue us and in reality nothing will come out of the lawsuit because we have the patience written document signed by him that this is the kind of end of life care for me it's like a waiver that they have to sign yeah everything has to be documented that they really
• 41:00 - 41:30 wanted to allow natural death no more aggressive life-sustaining measures for them wow that's very interesting now many of the people who will be watching this uh this discussion are students no second year students of feu and i would like to ask you what are the pointers or advice that you can give them should they face this uh ethical dilemmas especially when they have to deal with dying family members you know let's say they are the ones who are pregnant you know or they are they have impregnated
• 41:30 - 42:00 someone because we have been talking about the beginning of life and the end of life issues correct bioethics what are the key points that you would like to impart to our students well we talked about basic human right right right to life but we cannot also forget the fact that why is right life so important no so ultimately it's not just that life is valuable but also the idea that life is sacred
• 42:00 - 42:30 and why is it sacred because in the first place we are not the owners of our life we are merely stewards of our life so regardless of religion usually all of us believe that obviously we did not give our own lives to ourselves right we did not create our own life so somebody higher bigger supreme than we are gave us that life but only to take care
• 42:30 - 43:00 of to the best of our ability no so and therefore whenever you're faced with dilemma that will touch on life you will be accountable not only to the to the person you are serving but ultimately to the creator who gave that life to that person right so you might say it's the patient requesting for it eh it's his life well he had no right to make that
• 43:00 - 43:30 decision because his life was not his ultimately he will have to be accountable to his maker and if a doctor i want what is best for my patient i want him to be happy not just here but happy eternally and that's how i always discuss it with them you may be able to get away from the suffering of this life asking for euthanasia for
• 43:30 - 44:00 example but there's such a thing as the other life and it's even the eternal life and because of your unethical choices here it will redown to eternal suffering i think we'd rather suffer here because anyway it's going to end soon and i'm going to make you as comfortable as possible so it's never to forget that human life is sacred and each of us is so unique that even twins
• 44:00 - 44:30 are you might even say identical twins are still unique because they're only seemingly identical externally but when you go at the level of the molecules they're not their genes are not the same that's why not there there are differences in the organs and in in their genetic code and ultimately there are two different souls if you're a believer no there cannot be you have the souls right maybe
• 44:30 - 45:00 in tweening yeah the the body was half in the process of human development but there's no such thing as half a soul no each person has his own soul so each and every one is unique and wanted and loved by their maker so if therefore even before you were created you were loved we as human beings how can we not love ourselves and how can we not love and other people so when you respect another person
• 45:00 - 45:30 ultimately you're admitting the fact that i'm respecting the maker of this person as well so there's that accountability not only to the person concerned but ultimately to god no so they may not call that supreme being god but but i suppose even the atheist and those practicing natural religion would want to think that that there is a better life all of us dream of a better life not just here
• 45:30 - 46:00 somewhere sometime else yeah and you're right in saying that there are also universal values that are shared across across cultures right and you you usually use this as bases know when we make ethical decisions because i think the challenge now for young people is that there seems to be extreme moral relativism in our society that it's my life it's my body and all that and so it becomes a challenge for them when they have to make certain decisions based on these standards no because they
• 46:00 - 46:30 they make their decisions based on the situation can you elaborate on that that situational ethics that uh most people uh follow when they have to make certain decisions so in other words they're banking on their knowledge value and preferences and there's really nothing wrong with that except that you have to keep that a secondary to a higher measuring stick you know and the higher measuring stick the norm of morality
• 46:30 - 47:00 because the conscience which is all of us have is the subjective norm of morality i think this is right for me i think this is wrong for me so our conscience tell us that but even conscience follow what we call an objective norm of morality and this is the natural moral law and ultimately the natural moral law says do good avoid evil and what is good respecting life respecting the dignity of each person and knowing that your life is simply
• 47:00 - 47:30 lent to you you don't own it you have to give an accounting of how you lived your life to the one who gave you that life so then therefore it's no longer just subjective me and rather ultimately is what i'm doing uh in line with what the creator wanted for me and you know what in the end the creator only wanted us to be happy he made us for happiness he's preparing
• 47:30 - 48:00 happiness for us for as long as we obey his loss and his laws are not difficult wow this has been a very enlightening discussion doc i have never realized that there are a lot of things that we have to consider you know in this field called bioethics we have medical students here in feu we have um we have nursing students as well those in the medical field and i would like to ask you if there are specific sets of advice that you would like to impart to our students
• 48:00 - 48:30 as far as this issue on bioethics is concerned so in the end it's all about knowing the principles but more than just knowing is really reflecting on them and i would say you have to pray about them even if i have been practicing medicine for a long time and i am in the field of bioethics i teach it we discuss ethical dilemma right and left during the meeting of the by ethics
• 48:30 - 49:00 committee the institutional review board in the hospital sometimes you still have to ask for light to be able to remove all your biases and your own feelings into the matter because sometimes especially if you're taking care of the patient for a long period of time you have become close to the patient and the family it actually breaks your heart to lose a patient even no you cannot help but cry inside you whenever you lose a patient
• 49:00 - 49:30 you have to pray you don't have to rush yourself into a decision here and now so that in the end you always consider the patient's best interest the way we always advise family members and the ethics committee will be this is not about you because sometimes if you put yourself into the equation then it will complicate matters this is about a person who has entrusted his own life
• 49:30 - 50:00 in your hands and he has his own value system and ultimately what he wants is just what's best for him no and even if he may die still with some pain and suffering in the end we console him with the idea that it's not going to be wasted that pain and suffering would mean less pain and suffering in the other life right so you might say you're buying eternity
• 50:00 - 50:30 with your pain and suffering here and now no so and therefore you might say medicine is challenging medicine and nursing is tiring and you have to crack your brains literally and figuratively all the time but as long as you're happy in what you're doing you're at peace in the care of your patient and as you help them make those ethical decisions in the end it's going to be another day
• 50:30 - 51:00 for for the whole team no uh they need not suffer from burnout and even guilty consciences you know so and you and therefore you need the help of everyone you cannot do it on your own you know so among doctors we help each other we help the nurses with us no and then we guide the students every step of the way and also in other words in ethics we say if you're in doubt don't act resolve the doubt consult the experts read your books
• 51:00 - 51:30 consult the priest for example in in certain ethical dilemma or your pastor if you're a non-catholic and then only if you have a certainty that you have tried to resolve the doubt as best as you can only then should you act because once you have lost the life you can regain that life again so so that's why we solve the doubt and then act so that's how we do things in ethics thank you very much dr manalo this has
• 51:30 - 52:00 been a very enlightening experience for me personally because i didn't realize that medicine you know that the field of medicine is something that really requires individuals and people to make this tough decisions and you really have to be grounded on a certain set of moral values and standard to be able to surpass all of these challenges in your field so thank you very much once again and for our students just as a recap of what we have discussed dr manalo has
• 52:00 - 52:30 very credibly discussed the four principles uh in bioethics namely autonomy justice beneficence and non-maleficence which i think we should study further so that we will have a better appreciation of this discussion so thank you again dr manalo for your very kind accommodation of our request and thank you to our students for patiently participating in this discussion and see you again in the next session thank you very much to for for this opportunity to enlighten everyone because in the end
• 52:30 - 53:00 you know all we want is to make sure everybody has a very enjoyable life happy life and happy ever after all right thank you [Music]
• 53:00 - 53:30 you