The objective of this paper is to advocate for the restoration of traditional ethical approach in today’s palliative therapeutic care. To achieve this objective, I have first identified and argued against the modern approach’s weaknesses and how they undermine quality and effectives of therapeutic service. The paper clearly indicates that the merit of pharmacological revolution is the culprit responsible for its limited approach to the sufferings of terminally ill patients. To justify its limitations, bioethics has been redefined to appear legitimate but the fact is it that it is just an obvious disguise of a degenerated system of ethos. Thus, I conclude by supporting the traditional approach supported mainly by its holistic and humane ethical philosophies. This is the issue whose discussion has been done in section 3.
In section one this paper introduces us to a few selected ethical rules typically recognized in healthcare practice with their brief explanations. Section 3 illustrates how we can systematically define, analyze and resolve a confrontation of ethical values in a real life situation.
Every profession operates under defined ethical values which regulate the practitioner-client relationship with a view of satisfying the client’s effectively. In healthcare practice we have a number of ethical principles which regulate the healthcare professional’s therapeutic activities in respect to the patient. However, the prevailing ethics of a profession can be defined and redefined variously depending on the practitioners’ objectives and understanding of the situation which needs to be addressed. In this paper, we shall try to discuss how the ethical philosophy is being constructed and reconstructed in traditional and contemporary world with a bias on palliative care with a view of advocating for a return to traditional ethical approach.
Explanation of selected healthcare ethical principles
Ethical principles refer to the framework of moral values about what is right or wrong, good or bad meant to guide human behavior in a particular context. Because they are mental abstracts they are mostly characterized by dilemmas in their empirical applicability as we seek to respond to various human needs. Example, truthfulness is always considered good and lies bad. But yet there are certain circumstances under which contradictions (lies) can be equally considered good and truthfulness bad. Thus, choosing between what is right from wrong is highly dependent on our individual assessment of the situation that may vary.
To facilitate their caring relationships with their patients nurses as well as doctors acknowledge their allegiance to a number of ethical rules. This paper discusses some of them.
Justice is one of the universally most recognized moral values and is applicable in politics, law and ordinary life. However, its meaning is very controversial whereby people seek to modify it in order to justify their actions. Typically justice implies impartiality or fairness or non-discrimination and we all like to be treated so (Merriam Webster’s). Particularly the concept of justice is invoked in the context of distribution of scarce resources. In nursing profession, justice implies distributing available essentials fairly to all who need them without any form of discrimination due to age, gender, socio-economic status, or race.
However, application of this rule may be tricky more particularly when allotting medical essentials. Even without going far, justice may put a nurse or doctor on test when he/she is distributing his/her services especially in this era of healthcare manpower deficits. As it usually happens several patients may simultaneously need the service of one nurse or doctor. The nurse/doctor stands a chance of demonstrating their sense of distributive justice when choosing who shall be attended first from many. A choice based on race or relationships shall not be just. But a choice based on the comparative criticality of the various patients shall be fair. That is why critically ill patients don’t have to queue in congested health centers.
Sally Wehmeier et al. (1948) defined fidelity as “the quality of being loyal…” to somebody or something (p.546). In healthcare practice It implies being reliable and trustworthy to one’s patients. Hence fidelity is synonymous confidentiality. It about safeguarding the clients’ clinical information from the public in order to secure his or her right of privacy.
Merriam Webster’s dictionary defined veracity as “devotion to the truth”, “conformity with truth or fact”. Hence veracity denotes synonymy with truthfulness and honesty. It implies accuracy in the things that we do and say. Veracity creates the obligation of telling reality as it is about patient’s diagnosis, prognosis, clinical conditions and the consequences of suggested therapy in the patient’s goodwill. Sometimes, application of veracity may be controversial when truth telling may lead to potential harm or conflict with the patient.
This ethical value is derived from the Latin phrase primum nil nocele which is translated as “first do no harm” (The origin of primum non nocere). It hints that the healthcare intervention is never meant to create any damage. It is also an important aspect of therapeutic proportionality whereby it reminds the caregiver to be mindful about the possible consequences of his or her therapy. This is important because therapeutic “carelessness” has been the major cause of medical litigations against aggrieved patients.
It means to do good in the best interest of the patient. It is a twin sister of nonmaleficence. Childress and Beauchamp (1978) considered it as the fundamental principal of medical ethics whereby cure is the sole purpose of healthcare practice.
Is a system under which an authority undertakes to supply needs or regulate conduct of there under its control in matters affecting them as individuals as well as in there relations to authority to each other (Merriam Webster). In medical practice paternalism is justified by the proposition that the care giver is the expert with good intentions in the subjects’ welfare. Thus, paternalism can be viewed as a projection of beneficence (doing good) in the patient interest.
Autonomy implies the right for self-determination (Merriam Webster’s). In medical practice it calls for the listening and consideration of the patient’s demands and wishes. Patients can make demands which may at times conflict with the surrogate’s expectations and this creates ethical dilemmas.
Systematic ethical analysis of a sample case.
This section illustrates on how we can analyze a clinical case of a terminally ill patient following systematic procedures (Taboada, 2004, Systemization of ethical analysis of a clinical case).
A 30 years old man who has been undergoing Sedative therapy (for two years) due to Cancer attack in his intestines requests for euthanasia from the physician who actually kept quite. He eventually refused his sedatives therapy. However, his wife, parents, children, brothers and sisters (proxies) insisted that the doctor should continue administering the palliative therapy despite the patient’s wishes.
Clarification of ethical dilemmas
An adult patient requesting for induction of death creates several concerns. First of all we need to know why he thinks he deserves euthanasia. Secondly, we need to know whether his physician is under moral obligation to obey or disobey the conflicting wishes of the patient and his proxies. Finally, is it morally right for the patient to refuse therapy which has been assisting him for two years?
As by the mandate of the Hippocratic Oath the doctor is under moral obligation to do good (beneficence) through preserving, prolonging life or at least reduce suffering. This implies that physician assisted suicide is contradictory to this calling. On the hand, to what extent should the doctor obey the wishes of his client especially when he insists boycotting therapy? Whose wishes should he listen to? The patient’s or the proxies’? (autonomy). This inquiry clearly hints that the value of beneficence is colliding with the value of autonomy for the patient.
Our ability to make a wise choice depends on availability of important information. First, a re-evaluation of the effectives of the current sedative therapy may be necessary. This will assist reconfirm its utility or futility ratios. Eventually, the patient’s perception of the effectiveness of the therapy may also be important though at this stage he may seem to lack objectivity.
Secondly, there is need to gauge the patient’s mental faculty competence to determine whether his decisions are really out of his free will, well thought out, and are based on accurate and adequate information. This can be achieved through: A simple unilateral psychiatric observation. Examination of the patient’s clinical historical profile. Paying attention to the body language for any indications of anger, pain, anxiety, depression and communication problems. And finally, seeking of explanation from the patient if he is able to communicate rationally (Taboada, 2004, Systemization of ethical analysis of a clinical case).
Thirdly, information about the financial cost of therapy and who is reliable for pay, and capacity to afford is important. Sometimes patients may want to evade therapy due to affordability is issues. Finally the risks, costs and benefits of any potential course of action must be appraised, more especially possibility of aggravated or reduced harm and possibility for legal litigations.
Determination of possible courses of action
The suitable cause of action can only be determined once the collected data has been properly analyzed. For our case, the following alternatives are possible.
First, the doctor may grant the patient’s wish for euthanasia provided that:
a) There is a clinical justification for it in form of futility of intervention therapy and excessive pain. This can be perceived as a compassionate act for shortening sufferings associated with inevitable death.
b) If euthanasia is legally permissible and the due procedures for its acquisition are followed.
However, because many societies believe in sanctity of life this is very rare possible course of action. Secondly, availability of empirical evidence that the patient has undergone any form of incapacitation that considerably undermines his competence of authentic discretion, spontaneously delegates his autonomy to his proxies. However, this alternative may not work if the patient actually resists further cooperation. Finally, presuming that the patient is mentally sound then psychotherapeutic intervention seems to balance need foe beneficence and autonomy. Though this is usually time consuming, it is the best option which creates balance between the confronting values
The third alternative will respect the client’s autonomy as well as beneficence. A guidance and counseling therapy was conducted for the patient.
The client’s wish for death was based on the feeling that life was meaningless if death was very certain. He had three children in high school under which he felt like his expensive medical expenses should be invested in them. This was after two years during which his medical insurance cover expired and the family needed to sell its assets to pay for his medical therapies.
A discussion of the merits and demerits of traditional versus modern ethics in palliative healthcare.
One of the noticeable key achievements of modern medicine is its revolutionilized pharmacological interventions which help in quick fixation of “things”. Medical technology has invented substances which can suppress many pathological symptoms. A variety of sedatives are now available to alleviate pain caused by terminal clinical conditions like cancer. However,
Contemporary medicine’s ability to ‘fix’ certain types of suffering has produced a gradual shift in caregivers’ attention towards those types of suffering that are most fixable. Physicians tend to feel most competent when addressing conditions that they can understand anatomically, physiologically, and biochemically – the conditions for which pharmacological interventions are most readily available. ( Gunderman, 2002, p. 42).
Change is what distinguishes the past from the present. Existence of the modern implies that the traditional has been diminished. The modern approach to healthcare has been characterized by redefinition and reinterpretation of traditional ethical principles that guides its operations. “…new, more compassionate Medical Ethics, will offer practical solutions to problems we now find insoluble, and allow us to act compassionately and humanely, where our ethic now leads us to outcomes that nobody wants.”(Singer, P., 1994, p. 6). Singer felt that traditional bioethics was obsolete in that it would not keep in pace with the evolved medical technology. He suggested a reconceptualized framework or generation of ethics along the lines of the five “new commandments” namely: one, recognition that dignity of human life is variant. Two, respect for peoples’ freedom of choice between life and death. Three, avoidance of species discrimination. And four, taking personal responsibility for our decisions (Singer, 1994, p. 190-206).
In my opinion, singer’s perception of compassion undergirded by his new commandments seems really unconventional. However, I contend that it is pervasive too. Especially, if we relate it to palliative care for instance the implication we get is that a terminally ill patient progressively acquires a reduced value as his or her clinical condition gets worse. This is a very pessimistic and simplistic view of challenges of terminal illness. We should always have faith that sometimes miracles can happen when they are unexpected. He also seems to propose that physician assisted suicide needs to be unregulated. Thus he negates the value of sanctity of life which is in fact the foundation stone of medical practice. Instead true compassion does not belittle life, does not lose hope, does not shy away from problems and it even has faith in miracles. Hence, compassion is
… the virtue by which we have a sympathetic consciousness of sharing the distress and suffering of another person and on that basis are inclined to offer assistance in alleviating and/or living through that suffering. Therefore, there are two key elements of compassion: 1) an ability and willingness to enter into another’s situation deeply enough to gain knowledge of the person’s experience of suffering; and 2) a virtue characterized by the desire to alleviate the person’s suffering or, if that is not possible, to be of support by living through it vicariously. ( Dougherty & Purtilo,1995, p. 427).
Mostly, euthanasia on the terminally ill is supported on the basis of a therapeutic proportionality which is futile whereby the tormenting clinical symptoms of the patient are incontrollable by pharmacological mechanisms. Therefore it seems logical that induction of euthanasia is expression of compassion on the patient’s sufferings and the otherwise inevitable death has been quickened. However, such a system of thinking is based on a narrow understanding of human soul and human suffering. As by the traditions, human beings are biopsychosocial and therefore proper treatment intervention must be holistic in this manner. Hence, “the medical commitment towards a suffering person reaches far more than her body.” (Taboada, 2004, How do we conceive a more compassionate medical ethics?).
It should noted that the pestering problems that entrap patients are underpinned in anxiety, loneliness, despair and fear of beckoning death. Lack of meaning for life aggravates pain. It is more painful to have an empty sense of being than physical suffering as Gunderman (2002) puts it that: “What torments Tolstoy’s Ivan Illich most is not the physical pain he suffers, but the web of deception that ensnares him, his family, and his caregivers […] To deny suffering is to trivialize another person’s experience, to diminish its scope and lessen its significance. It is to falsify and invalidate the other person as a person” (p.43 – 44).
Therefore caregivers should recognize that it is not clinical suffering that destroys patients but rather that suffering without meaning. For that matter we can conclude that, “even though symptom control is an important aim of palliative care, it is not enough. The palliative care team is also called to help the patients in their search for meaning.” (Taboada, 2002, Caregiver’s ability to deal with suffering).
Thus, creating a good rapport with patients is a paramount ingredient which was inherent in traditional healthcare practice. However in modern palliative care practice this critical issue is usually taken for granted. There is an urgent for it to be revigorized. However, this will require a health professional to handle reduced number of patients in order have time for building relationships. This may automatically lead to increased deficit of healthcare manpower which may in turn call for immediate remedies. This demerit is recognized as the expense which can be incurred on the process. But yet the benefits shall justify the costs.
Another bad image of modern healthcare is that it has been commercialized. Contrary to the traditions today’s healthcare practice is no longer a special calling in favor of the troubled beings. Healthcare professionals have prioritized monetary gains at the expense of their patient’s needs. This is a trend that Gregory (1770) saw emerging early: the sympathetic physician with “sensibility of heart which makes us feel for the distresses of our fellow-creatures, and which, of consequence, incites us in the most powerful manner to relief them. Sympathy produces an anxious attention to a thousand little circumstances that may tend to relief the patient; an attention which money can never purchase. (Gregory, in McCullough 1998, p.38).
Because of lack of effective cure, death may be inevitable for the terminally patients. This marks the principal challenge in palliative care. Therefore we need to recognize that the patient’s fear or anxiety over death, sense of despair or isolation is major challenge which requires address. This a very critical area which modern therapeutic approach has ignored f taken for granted. As i have explained above, anti-depressants are not sufficient; we need to expand our modern therapy to spiritual, cultural and social therapies in order to promote healing. Besides, I have also tried to explain why there is no adequate justification for euthanasia as the ultimate solution for pain. The problem with it is that it is based on pessimistic view of suffering and a disguised form of sympathy. It limits therapeutic intervention to sedatives and anti-depressants thus undermining other forms of creativity which can promote healing and reduced pain.