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University of Balamand > Academics > Research > Seminars > Michel Daher

Ethical Issues in End of Life Care

Monday, March 3, 2008 from 12:30PM till 2:00 PM at the Jacobo Auditorium

SUBMITTED BY: Dr. Michel Daher, MD, FACS

INTRODUCTION: Ethics has been defined as "that branch of philosophy dealing with values relating to human conduct, with respect to the rightness and wrongness of certain actions and to the goodness and badness of the motives and ends of such actions." In a more practical sense, it has also been defined as "the rules of conduct recognized in respect to a particular class of human actions or a particular group, culture, etc."

In this review of the ethical issues confronting physicians who care for patients with advanced life-limiting illnesses, both definitions will be relevant since considerable philosophical debate continues in the medical community regarding the rightness or wrongness of certain actions (e.g., physician-assisted death) while at the same time there is a strong desire to find a common ground for moral discourse that could guide medical decision making in this difficult period in the lives of our patients.

Because of technical advances in the care of critical illness, physicians, patients, and families are often confronted with ambiguous circumstances in which medical advances may inadvertently prolong suffering and the dying process rather than bring healing and recovery. Excellent resources are available that review these issues in greater depth.

The objectives of this presentation are to: 1) review major principles of medical ethics relevant to the care of terminally ill patients; 2) explore further the principle of autonomy and its application to advanced directives, informed consent, and medical futility; 3) characterize the ethical differences between withholding or withdrawing life-sustaining therapies and physician-assisted death; 4) define a process for communicating bad news and negotiating decisions at the end of life; and 5) examine ethical problems specific to terminal illness (in the form of case scenarios) in light of these principles.


Suffering has been defined as "…the state of severe distress associated with events that threaten the intactness of the person." 4 Suffering or perceived suffering may often be the underlying issue that enervates many of the ethical conflicts that arise during the care of patients with advanced life-threatening illnesses. Different perceptions of a patient's suffering within the medical team (e.g., between nurses and physicians), between the medical team and family members, or within families can lead to conflict and are not infrequent reasons for ethics consultations in the acute care setting.

The goal of palliative care is to relieve suffering. The World Health Organization has defined palliative care as "the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems, is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families…" 5 Thus, the patient's suffering and the physician's mandate to address suffering provide the context for the application of four major principles of medical ethics: nonmaleficence, beneficence, autonomy, and justice.

  • Nonmaleficence and beneficence are Hippocratic principles, in which nonmaleficence specifically enjoins physicians to not harm patients (exacerbate their suffering) and beneficence goes further in insisting that physicians accomplish a positive good for their patients (relieve their suffering). For many centuries these two principles, in balance, have informed a medical paternalism in which physicians have held the primary decision making authority for their patients.

  • More recently, a third principle, i.e., autonomy, has become prominent, especially in Western Europe and North America. Autonomy recognizes the right of self-determination, or in the medical context, the right to establish one's own goals of care. With progression of an advanced illness there is increasing debility and loss of independent function that erodes a patient's autonomy. This progressive loss of autonomy, in as much as it further threatens the integrity of the person, adds to the suffering of those with advanced illnesses. Consumer autonomy, an extreme application of the principle of autonomy, views healthcare as a commodity to be purchased and received on demand. It has almost completely replaced the old medical paternalism with the concept that "the customer (i.e., patient) is always right," potentially leading to requests for inappropriate or futile medical treatments. In direct opposition to consumer autonomy, is the fourth major ethical principle, justice.

  • The principle of justice emphasizes the need for the equitable distribution of resources, including the often limited access to healthcare. An individual's desire or demand to have any and all potential treatments for an advanced incurable illness (consumer autonomy) may be in direct conflict with the just distribution of care for others who are also suffering, because of the limited resources available. Thus, the ethical responsibility of a physician to an individual patient is limited to the extent that utilization of resources for the individual unfairly compromises the ability to provide similar resources to others.

A practical extension of patient autonomy has been the development and use of advanced directives.

Typically, advanced directives can be in the form of a living will in which treatment preferences usually related to care at or near the end of life (especially regarding attempts at resuscitation) are documented or a durable power of attorney for healthcare in which a surrogate decision maker is identified (often one's spouse or other close relative).

In actual practice, advanced directives have not been as useful as hoped. It is almost impossible to anticipate every possible situation that might arise, especially during intensive care of a critically ill individual, in which specific decisions can be made in advance. Also, even when advanced directives have been prepared they are often ignored, either because of the urgent nature of a given situation and lack of ready access to the advanced directives or because of differences in interpretation of the specific wording of a living will.

In determining a patient's capacity for decision making the following criteria should be met: 1) the patient should be able to clearly identify a preference with regard to a specific intervention; and 2) the patient should demonstrate a clear understanding of the consequences of his/her choice and be able to clearly articulate this to his/her physician. Capacity for decision making can be determined by any physician. If the patient regains capacity for decision making (e.g., delirium resolves), the role of the surrogate decision maker is superseded by the patient's restored autonomy.

At this point, a digression is necessary to comment on the 'best interests standard' for incompetent or incapacitated patients. Under such circumstances, the physician must make the decision guided by the 'best interests standard'. When this standard is used to address practical problems, asking the question: "What is in the best interests of this patient at this time?" should help guide the medical decision maker(s) to pick from various options "that reasonable persons of good will would consider acceptable in similar circumstances


There is no fundamental difference ethically between withdrawing or stopping a treatment that is no longer beneficial and not starting or withholding such a treatment.16
Once a decision is made to withhold a "life-sustaining" treatment, other ongoing treatment should be reviewed as to the appropriateness of its continuation, as well.

The decision to withdraw life-sustaining therapy is rarely an emergency. It is essential to take all the time necessary to resolve any conflicts that may exist between the medical staff and family members or that may exist within the medical team. Clinicians should be aware that personal biases and values often play a dominant role in their clinical decisions (as opposed to objective data). All team members (attending physician, physicians-in-training, nurses, social workers, etc.) who have a direct role in the patient's care should have input in the process. As much as is possible, build consensus. Some important principles to consider when considering withdrawal of life-sustaining therapy include:
  1. All treatments can be withdrawn. If circumstances justify withdrawal of one therapy (e.g., intravenous pressors, antibiotics), they may also justify withdrawal of others.

  2. Be aware of the symbolic value of continuing some therapies (e.g., nutrition, hydration) even though their palliative value is questionable.

  3. Prior to withdrawing life-sustaining therapy ask the patient and family if a spiritual advisor (e.g., pastor, imam, or priest) should be called.
The rule or doctrine of 'double effect' is important to consider in any discussion of the role of palliative care in relieving the suffering of patients with advanced illnesses whether or not withdrawal of life-sustaining therapy is also under consideration. A treatment (e.g., opioid administration in the terminally ill) that is intended to do good and not harm the patient (i.e., relieve pain) is ethically acceptable even if a potential consequence (side effect) of its administration is to shorten the life of the patient (e.g., by respiratory depression).

The use of opioids for pain relief in advanced illness has been cited frequently as the classic example for the rule of double effect. However, it has been shown from a careful review of the literature, that in the vast majority of instances of opioid administration for symptom relief in advanced illness, the rule need not be invoked, since opioids can safely be used without significant risk, if administered appropriately. Some have used what they perceive as ambiguities in the rule of "double effect" in arguments supporting euthanasia and physician-assisted suicide.20 However; this principle ultimately rests on the intent of the individual acting under its guidance.

For the majority of physicians who would not willingly perform euthanasia, the rule of "double effect" underscores the reality that sometimes treatments with potentially dangerous side effects must be used to relieve the distress of our patients; but not with the intent of killing them in order to relieve their distress.21 To further clarify these issues, in physician-assisted suicide, a physician intentionally provides the means, while the patient is the direct, proximate cause of his/her own death. In euthanasia, the physician is the direct cause of the intended death of the patient.

With regard to medical ethics, there is no fundamental moral difference between physician-assisted suicide and euthanasia. Intent is everything, but document your intent. Thus, withholding or withdrawing treatments which are no longer beneficial or administering opioids for pain relief that may indirectly hasten death are not euthanasia.

In the ongoing debate regarding physician-assisted death (physician-assisted suicide or euthanasia), the most compelling argument in favor of the practice relates to suffering. If suffering is the greatest evil (which many advocates of physician-assisted death would endorse), then all means should be available to address it, including intentionally causing the premature death of one's patients. There are a number of reasons to resist embracing such a 'solution' to the suffering of our patients.
  1. Requests for physician-assisted death are often a sign of un-addressed issues including: inadequately treated physical symptoms (e.g., pain), untreated clinical depression, fear of a loss of control (autonomy), fear of being a burden, and potential existential or spiritual distress.

  2. Physical suffering can be relieved without writing a lethal prescription. Distressing symptoms can be controlled in >95% of cases with medications and supportive care. Terminal or palliative sedation can be used to control very difficult symptoms without taking a life.

  3. The end of life is a critical time for personal growth which would be shortened by premature physician-assisted death. During the last days and weeks of life a number of very important activities can occur including reconciliation and healing of relationships, life review, and spiritual growth as one searches for meaning in one's suffering.

  4. Legalization of physician-assisted death would be inherently unsafe. Patients with limited or unequal access to healthcare (e.g., the poor) would be particularly vulnerable, since physician-assisted death would inherently be quite "cost effective." There have been well documented failures or "problems with completion" of physician-assisted suicide (complications in 21 of 114 cases reported recently from the Netherlands) that could exacerbate rather than relieve the suffering of the dying.

  5. Physician-assisted death poses an inherent conflict of interest for physicians. Physicians can't remain as trusted advocates for the life and health of their patients, if they also may be the means of terminating that same life. With rising health care costs (particularly at the end of life), the pressure for more "cost effective" solutions (e.g., physician-assisted death) will mount. Physician-assisted death is in direct conflict with the Hippocratic Oath and tradition.

  6. Finally, physician-assisted death represents the very thing the terminally ill fear the most - abandonment. Although physicians may be able to address the physical distress of the dying, they may not have the skills or resources to address deeper, existential issues troubling their patients. This lack of knowledge does not justify taking a patient's life when others who may have the skills and patience are available to help.

Patients and their physicians together face a number of challenging ethical issues at the end of life. Although some issues (e.g., the role of physician-assisted death in addressing suffering) remain very controversial, there is much common ground based on the application of the four major principles of medical ethics, nonmaleficence, beneficence, autonomy, and justice.
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