There are four basic tenets of bioethics: autonomy, beneficence, nonmaleficence, and justice. Autonomy refers to self-rule and self-determination. Beneficence is action that is in the best interest of the patient. Nonmaleficence means to do no harm. Justice is the practice of treating patients in comparable circumstances the same way, and also refers to equitable distribution of resources, risks, and costs. Although bioethics is subject to change and reinterpretation, medical practice continues to rely on these principles to guide the actions of physicians and other health care providers.
The Hippocratic Oath
The earliest written document to deal with medical ethics is generally attributed to Hippocrates (circa 460–370 BCE), known as the father of medicine. For more than two thousand years the Hippocratic Oath has been adopted by Western physicians as a code of ethics, defining their conduct in the discharge of their duties. In part, the oath states:
I will follow that method of treatment, which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious [harmful] and mischievous. I will give no deadly medicine to anyone if asked, nor suggest any such counsel.
Nonetheless, some scholars claim that the giving of "deadly medicine" did not refer to euthanasia. During the time of Hippocrates, helping a suffering person end his or her life was common practice. The oath might therefore have been more an admonition to the medical profession to avoid acting as an accomplice to murder, rather than to refrain from the practice of euthanasia.
Some physicians believe that literal interpretation of the oath is not necessary. It simply offers guidelines that allow for adaptation to modern-day situations. In fact, in 1948 the World Medical Association modified the Hippocratic Oath to call attention to the atrocities committed by Nazi physicians. Known as the Declaration of Geneva, the document reads in part:
I will practice medicine with conscience and dignity. The health and life of my patient will be my first consideration…. I will not permit consideration of race, religion, nationality, party politics, or social standing to intervene between my duty and my patient. I will maintain the utmost respect for human life from the time of its conception. Even under threat, I will not use my knowledge contrary to the laws of humanity.
The Physician's Role
Even in ancient times, as can be gleaned from the Hippocratic Oath, physicians believed they knew what was best for their patients. Patients relied on their doctors' ability and judgment, and usually did not question the treatments prescribed. Doctors were not even required to tell their patients the details of their illness, even if they were terminally ill.
Beginning in the 1960s many patients assumed a more active role in their medical care. The emphasis on preventive medicine encouraged people to take responsibility for their own health. Physicians were faced with a new breed of patients who wanted to be active participants in their health care. Patients also wanted to know more about modern technologies and procedures that were evolving in medicine. With this new health consciousness, physicians and hospitals assumed the responsibility for informing and educating patients, and increasingly were legally liable for failing to inform patients of the consequences of medical treatments and procedures.
To compound the complexity of the changing patient-physician relationship, modern technology, which could sometimes prolong life, was also prolonging death. Historically, physicians had been trained to prevent and combat death, rather than to deal with dying patients, communicate with the patient and the family about a terminal illness, prepare them for an imminent death, or respond to a patient requesting assisted suicide.
Until the late 1990s, medical education programs offered very little in the area of end-of-life care. Drs. J. Andrew Billings and Susan Block reported that a 1991 survey of medical school deans revealed that only 11% of schools offered a full-term course on death and dying ("Palliative Care in Undergraduate Medical Education," Journal of the American Medical Association, vol. 278, no. 9, September 3, 1997). About 52% offered death education as part of other required courses, while another 30% offered only one or two lectures as part of another course. In 1997, while some medical schools offered information on dealing with death as part of other required courses, only 5 of 126 medical schools in the United States offered a separate required course on death and dying.
This situation began to improve in the late 1990s. The Education for Physicians on End-of-Life Care (EPEC) Project, developed in 1998 by the American Medical Association (AMA), is an ambitious training program that aims to provide physicians with the knowledge they need to care for dying patients. The curriculum emphasizes development of skills and competence in the areas of communication, ethical decision making, palliative care, psychosocial issues, and pain and symptom management. The program became fully operational in 1999 and provides curricula to all leaders of medical societies, medical school deans, and major medical organizations. The EPEC Project was supported from 1996 to 2003 with funding from the Robert Wood Johnson Foundation. After 2003 it was sponsored by and housed at Northwestern University Medical School in Chicago with a mission to educate all health care professionals on the essential clinical competencies in end-of-life care.
In 2002 Amy M. Sullivan and her colleagues surveyed associate deans at sixty-two accredited U.S. medical schools to determine attitudes and practices of end-of-life care teaching in the undergraduate medical curriculum ("End-of-Life Care in the Curriculum: A National Study of Medical Education Deans," Academic Medicine, vol. 79, no. 8, August 2004). Research results revealed that 29% of the deans surveyed reported that their medical schools offered courses or clerkships primarily focused on end-of-life care. However, two-thirds of the medical school deans admitted that not enough time was devoted
TABLE 3.1 Perceptions of associate deans of barriers to teaching end-of-life care at U.S. medical schools, 2002
| TABLE 3.1 | |||
|---|---|---|---|
| Perceptions of associate deans of barriers to teaching end-of-life care at U.S. medical schools, 2002 | |||
| Barrier | A lot | A moderate amount | Only a little/Not at all |
| SOURCE: Amy M. Sullivan, et al., "Table 3. Perceptions of 51 Associate Deans of Barriers to Teaching End-of-Life Care at U.S. Medical Schools, 2002," in "End-of-Life Care in the Curriculum: A National Study of Medical Education Deans," Academic Medicine, vol. 79, no. 8, August 2004 | |||
| Lack of time | 54% | 29% | 17% |
| Lack of faculty expertise | 21% | 32% | 47% |
| Lack of funding | 17% | 27% | 56% |
| Faculty perception that current teaching is adequate | 4% | 38% | 58% |
| End-of-life care is a low priority | 9% | 24% | 67% |
| Lack of faculty leader | 15% | 17% | 69% |
| Lack of clinical services | 2% | 19% | 79% |
| Lack of faculty interest | 2% | 19% | 79% |
| Lack of teaching materials | 2% | 15% | 83% |
in the curriculum to this topic. Table 3.1 shows the perceptions of these deans as to the barriers to teaching end-of-life care at U.S. medical schools. The most significant barrier is lack of time in the curriculum, followed by lack of faculty expertise and lack of funding.
Contemporary Ethical Guidelines for Physicians
Physicians are trained to save lives, not to let people die. Advanced medical technology, with respirators and parenteral nutrition (artificial feeding devices that provide nutrition to an otherwise unconscious patient), can prolong the process of dying. Dr. Ira Byock, in Dying Well: The Prospect for Growth at the End of Life (New York: G. P. Putnam's Sons, 1997), admitted:
A strong presumption throughout my medical education was that all seriously ill people required vigorous life-prolonging treatments, including those who were expected to die, even patients with advanced, chronic illness such as widespread cancer, end-stage congestive heart failure, and kidney or liver failure. It even extended to patients who saw death as a relief from the suffering caused by their illness.
The Council on Ethical and Judicial Affairs of the AMA published guidelines for physicians dealing with patients in nonemergency situations ("Decisions Near the End of Life," http://www.ama-assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/H-140.966. HTM). They were originally written in 1991, reaffirmed in 1996 and 1997, and appended in 2000. The following guidelines are the most recent as of this writing:
Our AMA believes that:
- The principle of patient autonomy requires that physicians must respect the decision to forgo life-sustaining treatment of a patient who possesses decision-making capacity. Life-sustaining treatment is any medical treatment that serves to prolong life without reversing the underlying medical condition. Life-sustaining treatment includes, but is not limited to, mechanical ventilation, renal dialysis, chemotherapy, antibiotics, and artificial nutrition and hydration.
- There is no ethical distinction between withdrawing and withholding life-sustaining treatment.
- Physicians have an obligation to relieve pain and suffering and to promote the dignity and autonomy of dying patients in their care. This includes providing effective palliative treatment even though it may foreseeably hasten death. More research must be pursued, examining the degree to which palliative care reduces the requests for euthanasia or assisted suicide.
- Physicians must not perform euthanasia or participate in assisted suicide. A more careful examination of the issue is necessary. Support, comfort, respect for patient autonomy, good communication, and adequate pain control may decrease dramatically the public demand for euthanasia and assisted suicide. In certain carefully defined circumstances, it would be humane to recognize that death is certain and suffering is great. However, the societal risks of involving physicians in medical interventions to cause patients' deaths is too great to condone euthanasia or physician-assisted suicide at this time.
- Our AM A supports continued research into and education concerning pain management. (CEJA Rep. B, A-91; Reaffirmed by BOT Rep. 59, A-96; Reaffirmation A-97; Appended: Sub. Res. 514, 1-00)
Another prominent professional medical organization, the American College of Physicians (ACP), revised its recommendations about end-of-life care in the fourth edition of its code of ethics, The American College of Physicians Ethics Manual (Philadelphia, PA: ACP, 1998, http://www.annals.Org/cgi/content/full/128/7/576). It is the most recent edition of the manual as of this writing. Its guidelines for decision-making near the end of life emphasize that capable and informed adults nearly always have the legal and ethical right to refuse treatment. They advise physicians to practice empathy, to compromise, and to negotiate with patients who wish to forego recommended treatment. The guidelines offer an approach to clinical ethical decision making that not only involves defining the problems and reviewing facts and uncertainties, but also considers the patient's emotional state, ethnicity, culture, and religious traditions.
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