Chapter 7 Ethics in intensive care

DEFINITION

Ethics is the study of how one ought to behave. In contrast, the law defines how one must behave to avoid punishment. Ethics is concerned with differentiating right from wrong behaviour. For most people, a sense of ethics is innate. Medical ethics particularly relates to the relationships between health care practitioners and patients and is not limited to doctors even if it is particularly applicable to doctors. Ethical conflict almost always involves a clash of values and appropriate resolution depends on recognition of the conflicting interests and values.

ETHICAL FRAMEWORK

Medical ethics are usually discussed in the context of principles. These principles inform ethical behaviour and can be summarised as:

1 Autonomy: the principle of individual self-determination in respect of medical care.

2 Beneficence: the principle of ‘doing good’, an obligation always to act in the best interests of patients with respect to saving lives, curing illness and alleviating pain and suffering.

3 Non-maleficence: the principle of doing no harm.

4 Fidelity: faithfulness to duties and obligations, a principle underlying confidentiality, telling the truth, keeping up with medical knowledge (i.e. continuing professional development) and not neglecting patient care.

5 Social justice: the principle of equitable access of all citizens to medical care according to medical need.

6 Utility: the principle of doing most good for the most number of people; that is, achieving maximum benefits for society without wasting health resources.

Utility is a consequentialist concept, where the right or wrong of an action is determined by the outcome rather than by an a priori principle. The ‘correct’ action may thus vary with the particular circumstances. This is sometimes seen as an entirely different framework from the rights or principles-based system. The utility principle is more applicable to systems development in medical practice and may create conflict with individual patient responsibility. It is important that intensivists participate in the public debate that determines how much of society’s goods are to be allocated to medicine and how much of the health budget is to be allocated to intensive care without, at the same time, surrendering responsibility for the interests of individual patients. Moving between these public and private spheres of functioning can be challenging but is essential to good medical practice.

Ethical conflict is most often encountered where there is a clash of values. Rationing, for instance, involves a clash between the values of individual rights and collective rights. Euthanasia usually involves a clash between the values of sanctity of life and autonomy. Resolution of ethical conflict depends on recognition of the values that are in dispute and of the principles that are operative. Absolutist terms such as ‘futility’ tend to mask the values-in-clash and are thus unhelpful in resolution of ethical conflict. Consideration of the various interests involved is also helpful in foregrounding the real issues behind an ethical conflict.

ICU ETHICAL PROBLEMS

END-OF-LIFE MANAGEMENT

During its relatively brief history, intensive care has seen a dramatic increase in both capacity and capability. Practice has become codified and at least partly standardised and intensive care is more generally accessible. Greater emphasis on individual rights has seen an increased demand for medical resources in general and this has flowed on to intensive care. The great challenge for intensive care lies in the reality that prolonged life support is often quite easily achieved without there being either inevitable recovery or intractable demise. Of the sickest patients in the intensive care unit (ICU), only a proportion ultimately recovers and can be returned to a reasonable quality of life. Even this would not be a problem if it were possible to predict survival with any degree of certainty and a great deal of effort has been expended in an attempt to achieve this. Unfortunately, this has met with only limited success and consideration of the appropriateness of ongoing intensive care is necessarily conducted against a background of prognostic uncertainty.¹

In consequence of this, death in ICU usually involves some limitation or withholding of life-sustaining treatment.^2,³ This has now been well documented in many studies from around the world and the driving factors are now reasonably well understood.²^–⁹ The ethical principles underpinning this practice are those described above. Intensive care is inevitably burdensome and requires a commensurate benefit to conform to beneficence and non-maleficence. While life itself has a value, this is considerably offset if it is brief, painful and non-interactive. As death becomes increasingly imminent, its deferment at any cost becomes less appropriate. Considerations of justice should rarely intrude at the bedside. However, prolongation of life by artificial means in a patient with little or no chance of survival may challenge the rights of survivable patients to limited intensive care resources.¹⁰ Where resources are publicly owned, offering to one patient treatment that cannot be made available to all patients in similar circumstances is fundamentally unethical. The collective has the ethical right to regulate access to even beneficial therapy provided it does so in a non-discriminatory fashion. The intensive care specialist does not have a right unilaterally to apply or withhold resources against the will of the collective. Unfortunately, the will of the collective is rarely known.

End-of-life management in the intensive care setting has been subjected to a considerable research endeavour over the past several years.^2,^4,¹¹^–¹³ Insights that can be gleaned from published studies include:

• Patients not infrequently die in some discomfort in ICU receiving unwanted therapy.

• Considerable dissatisfaction has been reported by both patients and families with management at the end of life.

• Patient wishes with respect to end-of-life treatment are commonly unknown.

• Patients and families may be quite ignorant of the nature and prognosis of end-of-life initiatives such as cardiopulmonary resuscitation.¹⁴

• Active interventions including obligatory, outside consultations have not been particularly effective in improving the quality of end-of-life management.

• There is a good deal of practice variability across countries and communities with respect to attitudes to death, dying and the withholding and withdrawing of active treatment.^2,⁸

• The reported variability in practice relates to attitudes of doctors and nurses, decision-making processes and to actual practices once a treatment-limiting decision has been made.

• Although some form of treatment limitation is common, withdrawal of treatment is not practised and is even illegal in some communities while active foreshortening and active euthanasia are reported in others.

• There remains some confusion concerning the distinction between active foreshortening of life and administration of drugs that both relieve unwanted symptoms and shorten the dying process. The nature and doses of agents used actively to shorten life are not necessarily different from those used to relieve symptoms without the intention of accelerating death and the time to death may also not be affected.²

• Most patients and families report a preference for some form of collaboration in end-of-life decision-making.¹⁵^–¹⁷