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
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: