Medical Ethics and the Elderly: practical guide

Gurcharan S Rai

• Editorial: Routledge
• Año: 2021
• ISBN:
  9781000446623
• Edición: 1
• Categoría: Betriebswirtschaft
• Categoría: Pharma-, Biotechnologie- & Gesundheitsindustrie

This concise, introductory handbook discusses the basic principles of medical ethics, and includes practical, realistic guidance on how to evaluate and manage common ethical problems, focusing on the care of elderly patients Typical scenarios faced in clinical practice, such as issues of mental capacity and consent, resuscitation, near death decisions, quality of life, and health care expenditure, are discussed

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Principles of medical ethics

K K Porter and G S Rai

Medical knowledge and technology have advanced at a spectacular rate. This voyage of discovery has led to a wealth of ethical issues unimaginable to the original followers of the Hippocratic Oath. Steeped in the history of philosophy and religion, the development of medical ethics has been an attempt to unravel and resolve the moral complexities and dilemmas that have faced doctors through the ages. Several tenets of medical ethics have stood the test of time and are embraced by modern day ethical guidelines. It is both impossible and undesirable to draw up codes giving specific instructions for every ethical scenario a practitioner may come across. What is essential is a basic and comprehensive framework upon which doctors can confidently rely in day to day practice.

There are four widely accepted general principles of medical ethics, which go towards such a framework: autonomy, justice, beneficence and non-maleficence. It has been argued that these prima facie principles represent a neutral frame of reference, applicable to all patients and situations and independent of religious, political or cultural doctrines.ⁱ

Autonomy

Autonomy is about respecting patients’ wishes and facilitating and encouraging their input into the medical decision making process. The issue of informed consent lies at the heart of this principle. To respect a patient’s autonomy is to give that individual a greater balance of power in the doctor patient relationship; it entails answering and explaining, not only what is wrong with that person, but the options for investigation and treatment and the associated risks and benefits. A doctor is duty bound to give truthful answers and to provide the patient with as much information as he or she wishes and requires to make a decision about their medical management.

Such information needs to be delivered in a clear and concise manner. A balance must be struck between confusing that individual with medical jargon and adopting an overly simplistic and patronising approach, which fails to include significant details. The art of pitching the consultation at the right level is by no means straightforward. But where possible the doctor should ensure that the patient understands his or her particular medical problem and management options. By following this principle the doctor should avoid the pitfall of using his or her own personal value system to judge what is best for the patient.

A poignant and real life example is that of a young women interviewed on daytime television about her decision to proceed with her pregnancy after being diagnosed with cervical carcinoma. As any potentially curative treatment would involve a hysterectomy, the woman was advised by her doctors to opt for termination. She decided against this and several months later after the birth of a healthy baby, the cancer had advanced beyond cure. This particular patient stated that she was made aware from the outset about the likely progression of the cancer should treatment be delayed. Though now terminally ill, she did not regret her decision. Of importance is that this individual, having been fully informed, was given ultimate responsibility to decide which management path to pursue.

A further example, in the setting of hospital geriatrics, is that of an eighty year old lady with a history of ischaemic heart disease and diabetes who was admitted with cardiac failure following a myocardial infarction. Her mental faculties were fully intact and she was making a steady recovery when her right foot became ischaemic. Conservative management was instigated but the foot could not be salvaged. The vascular surgeons explained on several occasions that in order to curtail the ascending ischaemia and to prevent potentially life threatening infection, she needed a below knee amputation. The considerable anaesthetic risk in view of her cardiac history was made clear, as was the probability of needing to remain in hospital for several weeks after surgery. The patient requested time to talk to distant family members and after further discussion with both the physicians and surgeons she declined surgery. Over the ensuing days her leg became gangrenous and she died from overwhelming sepsis. The case sparked differing view points amongst the junior medical staff, some felt that with the option of local anaesthetic block instead of a general anaesthetic, it was worth risking surgery to prevent this hitherto active individual dying from sepsis. Others felt that such a demise with dedicated nursing care and good pain control, was preferable to a long post operative recovery period and loss of independence.

These case scenarios though very different, illustrate how, when management options are no longer clear cut, the patient can play a pivotal role in guiding the doctor through an ethical maze. The principle of autonomy may be a noble ideal but its application can be limited. Patients may be unable to fully contribute to discussions about their care, an obvious example being emergency situation. This would also apply to patients with communication difficulties, after a stroke for instance. Sometimes patients may reject opportunities to exercise their autonomy and request that the doctor acts on their behalf, as evident in the statement “whatever you think best doctor”. Under such circumstances the doctor has to decide what course of action would be most appropriate for the patient but only after having given that patient the option to share in the decision making process.

A crucial factor in the above case scenarios is that both patients were deemed capable of autonomous decision making. Respecting autonomy becomes more complicated and can be fraught with difficulty in cases of mental incompetence. Deciding how to treat the elderly lady with the ischaemic foot would have been more perplexing had she also been suffering with severe dementia. In such situations the doctor is obliged to look beyond that individual in the hospital bed and to consider that patient in the context of her home and family, examine quality of life issues in other words. Other health professionals, family members and carers can provide invaluable information. The patient may have made her wishes clear to relatives before her mental deterioration or in the form of a living will. The ethical reverberations of mental incompetence and the issues of living wills and quality of life measurements are examined in detail in later chapters.

Justice

In the context of health care, justice implies an impartial and fair approach to treatment and the distribution of resources. Doctors discriminate unfairly if they allow their prejudices to directly influence their professional work. Established ethical and human rights codes condemn any form of discrimination on the grounds of age, race, sex, religion and sexual orientation. However, practitioners who are unwilling to treat patients who refuse to stop smoking are also guilty of prejudice. In recent times vascular surgeons have refused to treat cases of peripheral vascular disease in patients who continue to smoke against (well documented and proven) medical advice. Following this line of thinking, it would be permissible for physicians to refuse to manage obesity related problems in patients who do not adhere to a strict diet, or orthopaedic surgeons to decline treating patients with recurrent fractures sustained under the influence of alcohol. In view of this slippery slope, it is ethically unacceptable for doctors to refuse investigations and treatment based on their disapproval of the patient’s lifestyle. If, despite appropriate advice and information about the dangers of high risk activities such as smoking, a patient continues to take that risk, that decision must be accepted by the doctor who in so doing is effectively respecting that patient’s autonomy. At the same time, encouraging patients to take responsibility for their medical problems is also to respect their autonomy.

A caring society demands that limited resources are allocated in a just manner. The Oxford Dictionary of Philosophy defines distributive justice as “the link between a distributive system and the maximisation of well being”. Difficulties arise because of the inevitable scarcity of resources and subsequent conflicts between competing speciality groups. Health professionals have to recognise legitimate competing concerns and to acknowledge the prioritisation of patient needs. When a potential treatment of proven benefit is wanted for patient X, the doctor must be prepared to argue X’s case with colleagues and managers. The resulting joint or majority decision may be that due to the overwhelming need of other patients, purchasing an expensive treatment for patient X cannot be justified. Examples of such outcomes include the withdrawal by some health authorities of infertility treatment and certain cosmetic operations from the National Health Service in the UK. These decisions have been condemned by patients and doctors alike and the debate continues.

In an era of spiralling health care costs, an ageing population and development of sophisticated treatments and procedures, the issue of health care rationing cannot be avoided. Central to this issue are questions of what we mean by human dignity and what level of basic care can still be deemed humane. Setting and defining the limits of an acceptable level of minimum medical care is a dynamic process requiring input from medical professionals, health managers, politicians and laymen alike. It has been argued that at the very least the aim of basic health care is to prevent premature death, to enable an individual to function as a productive member of society and when that is no longer possible, to alleviate distressing symptoms for the remaining duration of that individual’s life and as he or she approaches death.ⁱⁱ

Beneficence and non-maleficence

“Trust me I’m a doctor…” is the ultimate medical cliché. The reassurance it inspires rests upon the patient believing that his or her doctor’s overriding professional aim is to do good (beneficence). Trying to do good often entails risks and we therefore have to consider at the same time the principle of non-maleficence: to avoid doing harm. In essence we are looking at a cost:benefit ratio and of critical importance is that it is patient centred. A doctor must do what is in the best interests of the patient; this stance incorporates the principle of autonomy.

Outcomes considered beneficial by the patient might be a better prognosis and longer life expectancy, the relief of physical pain or the alleviation of mental angst. No two cases are alike, what may be suitable for one patient may be wholly inappropriate for another. A frequently cited example is that of two women with breast cancer each offered a mastectomy. The first woman agrees since she feels that the possibility of improving her chances of survival outweigh the risks and disfigurement of surgery. The second patient refuses as she considers she would be left profoundly disfigured. She feels that the resulting distress and anxiety would impair her quality of life to an extent that would reduce the benefits of a longer survival.

Defining what is of benefit and what constitutes harm is by no means clear cut, furthermore, the goal posts for a particular patient may change. Consider, for example, a diabetic patient who, in order to reduce her risks of diabetic complications and maintain a healthy life, stringently follows medical advice to omit sugar from her diet and to carefully monitor her blood glucose values. Some years later she develops ovarian carcinoma, cure is attempted but she eventually becomes terminally ill. The clinician’s priority is no longer simply diabetic control but symptom relief. What would be the benefit in aggressive blood glucose control or denying her favourite sweets and cakes when she has a but few weeks to live? What would be the harm?

The interplay between doing what is the patient’s best interests and avoiding actual harm are at the crux of the much debated issue of euthanasia. The notion of saving life underpins medical training, however, nowadays there is also a greater emphasis on examining the quality of life and the concept of dignified death. In the United Kingdom where euthanasia is illegal, doctors follow the doctrine of double effect, under which it is permissible to administer medication to alleviate distressing symptoms of terminal illness even though the patient may die sooner as a result. Of crucial significance is that the doctor’s overriding goal is to relieve suffering, not to shorten life.

Conclusion

All health professionals and carers require an ethical basis to their day to day work. Whether doing something seemingly straightforward, such as inserting a cannula to administer intravenous fluids, or completing “do not resuscitate orders”, doctors are undertaking ethical decisions. The onus of such decision making cannot and should not rest with the doctor alone. The media, and now the internet, are providing the public with information about medicine and health on an unprecedented scale, raising the profile of patient autonomy. Developments in biotechnology pose many moral questions and with increasing medical specialisation, ethical discussions require the input of the patient, a range of doctors and allied professionals.

The four general principles outlined above, though described separately, are clearly interlinked and should be employed together when trying to resolve a medical dilemma. These principles have limitations and do not necessarily provide us with obvious answers. However, they serve as pointers when faced with a bewildering array of ethical situations and form a basis for analysis and problem solving.

Further Reading

Gillon R. Medical ethics; four principles plus attention to scope. BMJ 1994;309:184–8

Garrett TM, Harold WB, Garret RM. Health Care Ethics Principles and Problems, Prentice-Hall, Inc 1993

Johnson AJ. Pathways in Medical Ethics Edward Arnold, 1990

Campbell A et al. Medical Ethics, Oxford University Press, 1997

ⁱ  Gillon, R., Medical ethics; four principles plus attention to scope. BMJ, 1994; 309: 184-8.

ⁱⁱ  Garrett, T.M., Harold, W.B. and Garret, R.M., Health Care Ethics Principles and Problems, 1993, Prentice-Hall, Inc.

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Determining mental capacity and competence

S Luttrell

The right of a mentally competent adult to refuse ...