The passive euthanasia or limitationon of the therapeutic effort (LET) is a medical act that consists of withdrawing or not starting a treatment, both pharmacological and instrumental, that would not be of benefit to the patient, their pain or suffering.
Today it is considered a legitimate medical practice, synonymous with good practice, due to a paradigm shift in medicine in which more importance is given to the general condition and quality of life of the patient than to their mere survival (Borsellino, 2015; Baena, 2015).
Therefore, LET should not be confused with euthanasia or assisted suicide, illegal practices in most countries of the world..
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Thanks to technological advances and knowledge in medical science, today there are many tools that allow to keep a patient alive beyond what nature would have foreseen.
There is a wide spectrum of treatments and interventions that prolong life, but do not ensure recovery: artificial respiration, hydration or feeding, dialysis, cardiac resuscitation, or chemotherapy, to name a few (Borsellino, 2015).
However, the fact of survival is not a guarantee of quality of life or well-being, aspects that current medical science emphasizes much more than half a century ago.
Thus, according to Martínez (2010), doctors must examine and treat their patients in such a way that, at least, the effects of their actions always lead to an improvement in their quality of life.
This is why LTE does not imply in any case a limitation of care, since ensuring the well-being of the patient is as important as previous attempts to cure it (Winter and Cohen, 1999).
Therefore, situations are common in which life-prolonging treatment may not be the best for a patient with no hope of cure (Doyal and Doyal, 2001). It is at this time when the medical professional and the patient (or their relatives) can decide not to start or withdraw said treatment.
At this point, it is important to highlight that every patient of legal age and in full consciousness (or their family members) has the right to refuse any medical procedure, and it is never a decision made unilaterally by medical personnel (NHS Choices, 2017).
As mentioned before, LET has become a standard and widely accepted practice in recent times (Brieva, Cooray & Prashanth, 2009; Hernando, 2007).
Euthanasia is the action, by a medical professional, of intentionally ending the life of another person, usually a terminally ill patient, with the aim of saving pain and suffering.
The name "euthanasia" comes from ancient Greek and means "good death." Despite being similar to assisted suicide, it should not be confused with it. Assisted suicide implies that the doctor provides the means for suicide, which is subsequently carried out by the same patient.
However, in the case of euthanasia, it is the doctor who performs all the steps (Harris, Richard and Khanna, 2005). To date, both procedures are controversial and illegal in most parts of the world, with some form of them only allowed in less than a dozen countries (Wikipedia, 2018).
However, in the case of TBI, the death of the patient is not the direct consequence of the doctor's actions and, as mentioned in previous paragraphs, it is a widely accepted measure..
For example, a study conducted among Spanish medical professionals revealed that the vast majority of them (98%) agree with this procedure (González Castro et al., 2016).
A few decades ago, before it became the common practice that it is today, there was a debate within medical ethics and bioethics about LET. This debate focused on whether there was any moral difference between LET or "letting die" and euthanasia or "killing.".
Some authors such as Rachels (1975) argued that such a moral difference did not exist, and that in some cases euthanasia could be morally superior since it avoids the suffering of the patient to a greater extent.
Others, such as Cartwright (1996), argued that in the case of "killing" there was an agent that initiated the causal sequence, while in the case of "letting die" the person responsible was the lethal causal sequence..
At present, however, this debate is considered outdated and the only controversy lies in those cases in which the patient cannot directly express his consent, for example because he is in a vegetative state or because he is a young child..
In these situations, it is usually the family that has the last word, based on what the patient may have said at a previous time..
Likewise, it is also possible that the patient had signed a document declaring his will when he was in a conscious state, which is above the will of his relatives (NHS Choices, 2017).
An example of this controversy can be found in the media case of Alfie Evans, a British boy of almost two years of age who was born with a degenerative neurological disease.
In hospital since he was seven months old, he had no option for recovery, and the doctors claimed that the best, and most humane, course of action was to let him die..
Instead, his parents, supported by the Italian and Polish governments and the Pope, believed that Alfie did have a chance of survival, and refused to consent..
Finally, the British Court of Appeal decreed the withdrawal of the treatment that kept Alfie alive, as well as the prohibition of his parents from seeking new alternative treatments.
According to the court, continuing with the treatment would have only prolonged the child's suffering, which went against their own interests (Pérez-Peña, 2018).
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