End-of-life decisions: Ethics, cultural norms, and resource management

The technological advances of medicine in recent decades have made it possible to extend the life of critically ill patients even in resource poor countries in Sub-Saharan Africa. Modern biomedical technology restores some patients to health but also allows others to live in a severely disabled stage and prolongs the dying process for others. The increasing role of technology in prolonging life in severely debilitated patients, with no possibility of restoring health, is on a collision course with moral norms in many societies. Patients have a limited say on when to initiate these complex treatments and when to stop them in the absence of advance directives or living wills. Such directives may not be easily accommodated by African cultures where death is accepted as the will of God and rarely discussed until it arrives. To sustain the ‘life’ of a terminally ill individual with no chance of recovery on a machine at a high cost to an impoverished family and community could be considered socially unjustifiable. The right of the patient to decline treatment when the quality of life becomes untenable continues to meet resistance from religious doctrine and cultural objections. These deep ethical and philosophical questions with no easy answers may continue to haunt individuals, families, institutions and communities for generations to come.