MEDICAL ETHICS andThe End of Life

ETHICAL THEORIES

• DEONTOLOGY

• CONSEQUENTIALISM

• VIRTUE ETHICS

• CRITICAL REALISM

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.”

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.

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

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?

• 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

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?

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• Be satisfied that it has not been revoked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• Forms• Time limits• Insurance• Insensitive• 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.

? difference

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

THANKYOU

• Niall.Cameron@nes.scot.nhs.uk

CK is a 74 year old woman who has a long history of phobic anxiety and depression, diverticulitis, COPD and was treated for Breast Cancer 10years ago. She attends you regularly and also sees the local community mental health team. She is on a large number of medications including anti-depressants. Her husband had given up work early to look after her. She developed increasing lower abdominal pain and was referred for GI review. Tests revealed a pelvic mass thought to be ovarian and her tumour markers were markedly raised. She was admitted for total hysterectomy and initially was given an encouraging prognosis from her surgeon. She was referred for chemotherapy but before starting this developed a fistula and need a surgery to form a colostomy. She then went on to complete a course of chemotherapy. Following this the tumour markers initially fell but soon after she developed increasing lower abdominal pain and the tumour markers were markedly elevated. She looked and felt very unwell with significant weight loss. When seen by the oncologists they suggested further chemo therapy and this was agreed to by the patient and her family. After two further treatments you were called to see her at home by her husband. He was concerned she was unwell and would not be able to attend for the next scheduled treatment.

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