Transcript No Slide Title

MEDICAL ETHICS and
The 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 sound
mind 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 professionals
to promote their patients’ autonomy or at least not
interfere with it.
COMPETENT
Understand information, retain it, believe it
and make a decision on the basis of
that 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• Be satisfied that it has not been revoked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
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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
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? 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 keep
them alive or stop doing something that
is keeping them alive.
Active - carries out act with intention of
causing death.
? difference
Arguments Against Euthanasia
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Religious
Ethical
Practical
Social
Historical
Inappropriate
• SLIPPERY SLOPE ARGUMENTS
initial 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
• [email protected]
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 curative
treatment.
•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