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MEDICAL ETHICS andThe End of Life
PRIMA FACIE DUTIES
• AUTONOMY
• BENEFICENCE
• NON - MALEFICENCE
• JUSTICE
• UTILITY
AUTONOMY
The ability to be self governing and self directing
• truth telling
• informed consent
• confidentiality
“Every human being of adult years and soundmind has a right to determine what shall be done with his own body.”
COMPETENT
Understand information, retain it, believe itand make a decision on the basis ofthat information.
Understand benefits and risks of treatment
Understand what will happen if no treatment takes place
Have the capacity to make a choice
AUTONOMY MAY BE
• TEMPORARILY IMPAIRED
• FLUCTUATE
• TOTALLY ABSENT
• RESTRICTED BY OTHERS - PATERNALISM
Implies a duty on the part of health professionalsto promote their patients’ autonomy or at least notinterfere with it.
AUTONOMY
DOES IT IMPLY RIGHT TO DIE?
OR
RIGHT NOT TO BE KEPT ALIVE?
OR
RIGHT TO BE KEPT ALIVE?
BENEFICENCE/ NON - MALEFICENCE
• DOING GOOD
• ACT IN BEST INTERESTS?
The goal of palliative care is achievement of the best quality of life for the patients and their families.
• PRIMUM NON NOCERE first do no harm
What if there are competing harms?
JUSTICE
• fairness, non discriminatory behaviour
UTILITY
• the greatest good for the greatest number
• rationing resources
• availability of services
WITH-HOLDING AND WITHDRAWING TREATMENT
• Anthony Bland 1989 - ? TREATMENT
• Futility of treatment – Do not strive officiously
•DNR
•LCP
Quality of life is believed to be so diminished that it is no longer desirable.Designed to prevent unnecessary suffering
ADVANCE DIRECTIVES
A mechanism whereby competent people
give instructions about what is to be done
if they subsequently lose the capacity to
decide or communicate. It is most often
used in decisions about medical treatment,
particularly the treatment which might be
provided as the patient approaches death.
ADVANCE DIRECTIVES
• Specify treatments they are refusing or requesting!
• Trigger event should be specified
• Be satisfied that it has not been revoked
• No change of mind or circumstances
• Written and witnessed
• Discussed with a health professional
• Reviewed and updated
• Any doubt - preserve life
Advantages
• Satisfy Autonomy• Discussion• Encourage naming of proxy• Pressure off relatives and HPs• Increased clarity about wishes• Assurance that treatment accords
with values and preferences• Some indication is better than none
Problems
• ? Emergency treatment• Non-specific• Change of mind• Obliged to have one/Insensitive• Forms/Time limits• Insurance• Futile treatment?
EUTHANASIA
A gentle or good death
• Voluntary - at their request
• Non-voluntary - no capacity to refuse
• Involuntary - competent people are killed against their will
• Physician assisted suicide - patient requires assistance to commit suicide
ACTIVE v PASSIVE EUTHANASIA
Passive - don’t do some thing to keepthem alive or stop doing something thatis keeping them alive.
Active - carries out act with intention of causing death.
Physician Assisted Suicide
? difference
DOCTRINE OF DOUBLE EFFECT
• Foreseeing is not the same as intention
•If the patient were not to die after my action would I feel that I had failed to accomplish what I had set out to do?
•Assisted suicide?
Arguments Against Euthanasia
• Religious• Ethical• Practical• Social• Historical• Inappropriate
• SLIPPERY SLOPE ARGUMENTSinitial actions will eventually lead to
undesirable or unwanted consequences.
THE LAW AROUND THE WORLD
• HOLLAND - unbearable suffering with no prospect of improvement
• AUSTRALIA - Rights of Terminally Ill Act
• OREGON - Death with Dignity Act
• BELGIUM 2002
• SWITZERLAND - Dignitas
UK AND SCOTLAND
• Assisted Dying for Terminally Ill Bill
• Physician Assisted Suicide Bill
• DPP guidelines
DEALING WITH ETHICAL PROBLEMS
1. Get the story straight
2. Intuitive initial reaction.
3. Identify ethical problems.
4. Conflicts
5. Alternatives?
6. Apply principles
7. Professional and legal requirements
8. Discuss with colleagues
9. Decision
10. Anticipate criticism, be prepared to justify your decision and reconsider
DECISION MAKING
• Guidelines
• Professional Bodies
• Regulatory Bodies
• Legal Considerations
• Personal Values - HPs and Patients
• Medical Ethics
• Common Sense
PALLIATIVE CARE
•The active total care of patients whose disease is not responsive to curativetreatment.
•Control of symptoms is paramount.
•The goal of palliative care is achievement of the best quality of life for the patients and their families.
PATIENT CONCERNS
Symptom control
Retain control
Avoid prolongation of dying
Decrease the burden on family
Improve relationship with family
ETHICAL THEORIES
• DEONTOLOGY
• CONSEQUENTIALISM
• VIRTUE ETHICS
• CRITICAL REALISM
