Ethics in intensive care

Chapter 7 Ethics in intensive care





ETHICAL FRAMEWORK


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








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.29 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.2,4,1113 Insights that can be gleaned from published studies include:












Jul 7, 2016 | Posted by in CRITICAL CARE | Comments Off on Ethics in intensive care

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