Ethical Issues in Palliative Care

Ethics refers to the rules or standards governing the conduct of individuals or members of a profession. As members of medical profession our conduct is governed by medical ethics.

The four cardinal principles of medical ethics provide a frame work for decision making in difficult situations. They are-

1. Respect for patient’s autonomy
2. Benefience or ‘do good’
3. Non maleficence or ‘ do no harm’
4. Justice or fare use of available resources.

Autonomy is an expression of informed choices and preferences or consent to whatever we do or is done to us by others. It acknowledges the patient’s right to know the diagnosis, to know the details of the treatment offered to him/her, and the right to refuse treatment.

Beneficence means that whatever one does to the patient should be good to the patient.

Non maleficence means one should not do any harm to the patient while giving care or treatment to the patient.

The resources are limited and the demands are high. Justice is the principle of fare use of the available resources. It concerns with balancing needs of individuals with those of society.

Mr. X is a 50 year old man with for advanced cancer of stomach. He is a manual labourer and works hard to support his family with wife and four children. Now his eldest son is grown up and earning. When Mr.X became ill, he refuses food and fluids. His wife and children are upset at the thought that when they reached a point  when Mr.X can sit back and enjoy the fruits of his labor, he is unable to eat. They insist the doctor to put in an NG tube or give him IV fluids. How do the ethical principles apply in the above clinical scenario?.

Respecting the autonomy means not to force feed him. Before taking such a decision, we have to be sure that his opinion came as an informed choice and not under any undue external pressure. To ascertain this we have to communicate with the patient effectively. Psychological assessment must be done to rule out clinical depression, and anything correctable should be corrected. If we know that Mr.X’s decision not to take food or fluids came as an informed choice, we should respect it. According to the second principles of beneficence, artificial hydration or feeding should be given only if it does any good to the patient. Terminal hydration and nutrition do not improve the quality of life or longevity of terminal patients. The third principle is non-maleficence. We are justified in giving artificial hydration and nutrition only if it does not produce any harm to the patient. A problem with artificial hydration in a terminally ill patient is circulatory overload and the resultant pulmonary edema. The principle of justice has not much relevance in this situation unless we plan for total parenteral nutrition which has a bearing on the resource potential.

Now the question is to address the relative’s concern. Again skilled communication is needed. They should be informed in a sensitive manner the futility of hydration and nutrition in such patients and the possible adverse effects of such treatment.  In this cultural milieu it is important that we respect the wishes of the immediate care givers also. This can be done by making the care givers participate in the decision making.

The primary goal of medical treatment is to benefit the patient. If a patient has refused the treatment or if the patient lacks financial capacity and the treatment would fail or cease to provide a net benefit to the patient, the treatment should, ethically and legally be withheld or withdrawn. Good quality care and palliation of symptoms should however continue. Medical interventions may have some benefit and some risk or burden to the patient. It means withhold or withdraw treatment when the risk or burden outweighs the benefit. The doctor has to assess the situation individually and decide upon instituting a particular treatment when it seems to be beneficial and he/she should have the courage to stop the treatment when the burden or risk outweighs the perceived benefit.

The aim of medical care should be to provide best possible quality of life. Towards the end of life the biological prospects are slim and the ethical imperative is to focus on quality of life rather than the duration of life. It is important to ensure participation of the patient in the discussion regarding reorienting the goals of care. How far the patients should be involved is a difficult question. Doctor should explain to the patient the therapeutic possibilities and the odds for success, explore the patient’s goals, values and expectations and assist in arriving at a decision. In real life situations many patients would like the doctor to take decision for them. It is the moral responsibility of the treating doctor to help patients take decision.

Towards the end of life the health condition is very fragile. Drugs used or procedures done at that time, which have a potential for adverse effects may be blamed for the death. Traditionally the ‘doctorine of double effect’ is cited as justification for instituting such therapy. The doctrine of double effect states-“ A single act having two possible foreseeable effects, one good and one harmful, is not always morally prohibited if the harmful effect is not intended”.

A clinical scenario can be used to demonstrate the doctrine. Mr. X is having far advanced carcinoma stomach with severe pain and panic reaction. He was given parenteral morphine to relieve the pain and panic. In a few minute he dies. Can morphine be responsible for the death and is the prescribing doctor punishable as respiratory depression is a foreseeable effect of that drug? As per the doctrine so long as the intention of giving morphine was not hastening death, the prescribing doctor is not guilty of the outcome even if that effect was foreseeable.

Many times relation insists an terminal care in sophisticated ICU. They want to show the world that they did everything available on earth to treat their kith and kin.With the advent of modern technology it is now possible to prolong the dying process by artificial ventilation and cardiac support.  Most of the time it runs contrary to the wishes of the patients. It does not conform to the notion of ‘ good death’ either. But is it morally justified to stop life prolonging or life sustaining treatment? The decision has to be taken on an individual basis. Ethical principles should be applied against the background of respect for life and the acceptance of the ultimate inevitability of death. Indian law doesn’t have specific guideline for limiting life support in the end of life care. But there are certain constitutional and legal provisions which can be used by the treating physician to limit further suffering.

Ethical principles are useful only as a broad guideline for patient care. Compassion and common sense should be combined with professional knowledge and skill. While applying ethical principles one should employ good communication skills at all levels. Essentially it is working together with the patient and family taking into consideration their religious and cultural background.

Dr.A.K.Dewan
Director-Surgical Oncology