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PubMedDate not supplied

Ethical principles: application to an obstetric case.

This article focuses on the application of the ethical principles of double effect versus consequentialism, autonomy, beneficence, utility, and justice. An obstetrical case study is presented and discussion of each ethical principle is used to resolve the conflict. The intents of the article are to promote ethical awareness; provide topic areas to facilitate ethical discussion; enhance nurses' knowledge of the discipline of ethics; and support the necessity of interdisciplinary ethics committees.

Beneficence↗
PubMed1991

Is it morally justifiable not to sedate this patient before ventilator withdrawal?

In their case description and analysis, Barbara Springer Edwards and Winston M. Ueno provide a nice opportunity to examine the intersection of theory and practice in medical ethics, as well as to discuss the fine tuning of treatment decisions in the clinical setting. They raise the question: Is it morally justifiable to sedate an alert patient before his life-supporting ventilator is disconnected? Clearly they have a thorough understanding of their patient's legal and ethical entitlement to have his request for discontinuation of life-supporting treatment honored. They also recognize the principle of double effect in allowing large doses of medication to control pain even at the risk of accelerating death. My doubts lie in their specific application of the notion of beneficence, a principle that involves mainly two objectives: preservation of life and alleviation of suffering....

Altruism↗
PubMed1999

Ethical issues in palliative care.

The relief of suffering is one of the aims of health care. Pain relief is a moral obligation in health care, not an optional extra. Doctors have moral obligations to strive to relieve pain, to be competent in basic pain control, and to endeavour to give patients an adequate understanding of their illness and painkillers. The most common moral problem in pain control in terminally ill patients is the conflict between the obligation to relieve suffering and the obligation to prolong life. The law prohibits intentionally causing the death of another person. Debates follow as to what constitutes an intention to cause death, and what actually constitutes a cause of death. At present, doctors are legally permitted to give sedatives and analgesics to terminally ill patients with the intention of relieving suffering, even if life is shortened. The moral principle of the 'double effect' relates to this and is explained. It relies on a distinction between intended and foreseen effects of treatment. Some people dispute the distinction between intended and foreseen effects and claim that the principle of double effect allows doctors who intend euthanasia to carry it out under cover of the law. This debate is explored in the article. Finally, is it ever morally justifiable to end the patient's life on the grounds that this is the only way to end pain? Even if it is, should euthanasia be legalised? A brief comment on these issues, and the roles of law and morality, are made.

Ethics, Medical↗
PubMed1992

Ethical dilemmas in pediatric critical care.

Advances in the area of pediatric medicine during the past few years have presented ethical dilemmas for the physician to consider. This article discusses the ethical principles upon which clinical reasoning and judgments can be made.

Beneficence↗
PubMed1992

Pain relief: the perspective of Catholic tradition.

Efforts to study patient care from the perspective of Catholic ethics date back four centuries. In the course of this history, a prominent issue has always been management of pain and the efforts to avoid pain. Thus, Catholic theologians were concerned about the effects of pain medication upon the psychic function and considered whether or not hastening death for suffering people was allowed and the ethical norms for using opioids to remove pain when death is imminent. Moreover, the issue of "overmedication" for difficult or elderly patients has been a concern. The President's Commission on Ethics in Medicine and Human Research has utilized many of the principles developed by Catholic theologians when considering the matter of pain relief for dying persons.

Attitude to Death↗
PubMed1987

Euthanasia: a Catholic perspective.

According to the Roman Catholic perspective, we are not obliged to ward off death at all costs, but we should not deliberately intervene to bring death about. The "sanctity of life" principle, which rests on the human person's unique relationship with God, is the basis of the Church's honoring of human life as a basic value. Under this principle, direct intervention to end the life of a patient in a terminal condition would not be condoned. This negative position also follows from the religious principle of divine sovereignty--the idea that God alone is Lord over life and death, and the end of human life is not subject to a person's free judgment. Catholic moral tradition distinguishes between actions, on the one hand, or omissions that constitute intervention to put the patient to death and, on the other hand, the withholding of useless treatment that could not significantly reverse or prolong the progressive deterioration of life. The distinction rests on the difference between ordinary and extraordinary means. Also to be considered is the intention--the physician's goals versus the foreseeable yet unintended results. Thus death may not be directly sought, but it may be tolerated as an inevitable side effect of one's goal (such as the relief of suffering). These moral principles need to be rooted in the specific ways a moral community cares for its sick and dying. The religious convictions of grace and covenant and corresponding virtues of gratitude and fidelity enable the community to uphold its convictions about euthanasia.

Catholicism↗
PubMed1993

Limits of patient autonomy. Physician attitudes and practices regarding life-sustaining treatments and euthanasia.

BACKGROUND: In making decisions about life-sustaining medical interventions, respect for patient autonomy has been widely advocated, yet little is known about what variables may compete with a physician's ability to honor patient requests in clinical situations. We investigated physician attitudes and behaviors about end-of-life decisions by means of a questionnaire that posed five hypothetical scenarios in which an elderly, competent, terminally ill patient made a request that, if agreed to by the physician, could result in the patient's death. METHODS: We surveyed 392 physicians in Rhode Island and asked them to decide (1) whether or not they would comply with a specific patient request, (2) the justifications they used in making their decision, and (3) whether they had been approached with such a request in their clinical practices. RESULTS: Two hundred fifty-six physicians (65%) responded. Of the respondents, 98% agreed not to intubate the patient in the face of worsening respiratory failure. Eighty-six percent agreed to give the patient a dose of narcotics that could cause respiratory compromise and death to treat his pain adequately. Fifty-nine percent agreed, once the patient was intubated without hope of coming off the respirator, to turn the respirator off. Nine percent agreed to give the patient a prescription for an amount of sleeping pills that would be lethal if taken all at once. Only 1% agreed to give the patient a lethal injection. When they complied with patient requests, physicians cited patient autonomy as the principle most important to their decision making. Physicians who would not comply with patient requests also, paradoxically, often cited this principle but agreed with it less strongly; others cited concerns about the ethical nature of the request, legal questions, and the perception that they were "killing the patient." Sixty-five percent of respondents had been asked by patients to turn off a respirator, and 12% had been asked to administer lethal injections. Twenty-eight percent of respondents indicated that they would comply with requests for lethal injection more frequently if such an action were legal. CONCLUSIONS: Difficult clinical decisions regarding potentially life-prolonging measures are commonly heard in clinical practice. Physicians value the concept of patient autonomy but place it in the context of other ethical and legal concerns and do not always accept specific actions derived from this principle.

Adult↗
PubMed1997

Ethical issues in pain management.

The modern hospice movement has played a significant role in the development of palliative care. Effective palliation is of crucial importance in achieving quality of life and a dignified death for the terminally ill. While the inherent risk in palliative care, respiratory depression, remains an open medical question, an understanding of the ethical and moral principle of double effect demonstrates the prudential nature of palliative care and how it is an application of the ethical and moral norm, respect for patient autonomy.

Ethics, Professional↗
PubMed1994

Ethics and pain management: respecting patient wishes.

The fear of pain is common among cancer patients. The management of cancer pain can raise troubling ethical issues for medicine and society. Medical caregivers have an ethical duty to provide therapy that benefits patients by achieving one or more goals of medicine at all points. Pain and symptom relief may be the only achievable goal when curative therapy has failed. Relief of pain can restore decision-making capacity and enhance the patient's right to self-determination. The underpinning ethical principles and extensions of these principles in the medical context of pain control with varying medical goals in cancer care, including dying patients, is explored.

Beneficence↗
PubMed1994

Pain management and potentially life-shortening analgesia in the terminally ill child: the ethical implications for pediatric nurses.

Optimal pain control in the dying child often requires aggressive opioid therapy that exceeds recommended parameters and may hasten death caused by respiratory depression. For pediatric nurses caring for the dying child, the administration of potentially life-shortening analgesia gives rise to a number of ethical issues. Pediatric nurses often express concern that aggressive pain control is a form of euthanasia or fear the child will develop a drug dependence. Lack of clarity about the ethical obligations and professional responsibilities of nurses who administer potentially life-shortening analgesia may also contribute to the dilemmas surrounding such situations. If left unresolved, these issues can interfere with the nurse's ability to implement an appropriate pain regimen. To provide adequate pain control, pediatric nurses who care for dying children must accomplish the following: critically examine ethical issues and underlying principles; understand the phenomena of addiction, tolerance, and physical dependence; and identify the boundaries of acceptable nursing practice when administering potentially life-shortening analgesia to terminally ill children.

Child↗
PubMedDate not supplied

Ethical perspectives: opioid treatment of chronic pain in the context of addiction.

The authors apply eight ethical domains of analysis to the question of treatment of chronic pain with opioids in patients with histories of substance use disorders: autonomy, nonmaleficence, beneficence, justice, medical condition, patient preference, quality of life, and consideration of specific individual or sociocultural issues. These eight domains are drawn from principle-based and case-based ethical perspectives. The domains are developed by review of available literature and through application to a specific presented case. Factors that interfere with rational, ethical decision-making regarding opioid pain management are identified. Chronic pain and substance use disorders share a history of stigmatization, underdiagnosis, and undertreatment. Using the presented case as a point of departure, the authors discuss principles for prescription of opioids for treatment of chronic noncancer pain in the setting of history of substance use disorders.

Chronic Disease↗
PubMed2005

Ethics in pediatric end-of-life care: a nursing perspective.

Care of children at the end of life frequently involves ethical dilemmas and difficult decisions. These ethical dilemmas often complicate the already challenging circumstances surrounding the death of a child; therefore, the knowledge and application of ethical principles becomes an essential component of nursing practice. The purpose of this article is to describe bioethical principles and common ethical dilemmas faced by nurses in pediatric end-of-life care and suggest nursing interventions to promote a peaceful end-of-life experience for the child and family.

Adolescent↗
PubMed2002

Sedation, alimentation, hydration, and equivocation: careful conversation about care at the end of life.

In the recent medical ethics literature, several authors have recommended terminal sedation and refusal of hydration and nutrition as important, morally acceptable, and relatively uncontroversial treatment options for end-of-life suffering. However, not all authors use these terms to refer to the same practices. This paper examines the various ways that the terms terminal sedation and refusal of hydration and nutrition have been used in the medical literature. Although some of these practices are ethically appropriate responses to end-of-life suffering, others (at least as they are currently described in the medical ethics literature) are not. This paper identifies and discusses the principles that morally distinguish these practices from one another and specifically describes different features of medical practices and moral principles that affect the moral acceptability of various medical treatments. These distinctions reveal the complexity of the issues surrounding terminal sedation and refusal of hydration and nutrition, a complexity that has not been adequately addressed in recent discussions.

Adult↗
PubMedDate not supplied

Pain management. Theological and ethical principles governing the use of pain relief for dying patients. Task Force on Pain Management, Catholic Health Association.

Pain management is a societal problem because of concerns about the use of drugs, the belief that patients are not good judges of the severity of their pain, and an alarming level of ignorance about pain and its treatment among physicians, nurses, and other healthcare providers. The result is that patients suffer pain unnecessarily, even up to the point of their death. Pain management is also a clinical-practice problem. Courses in pain and symptom management are not readily available to medical and nursing students. And in clinical practice, good pain assessment is not easy to accomplish because pain is so subjective. Fortunately, with education, doctors and nurses can vastly improve their ability to assess and manage patients' pain. Additional problems in pain management relate to the manner in which healthcare is provided today: an acute disease-oriented model of hospital care, frequent transfers, fragmented care, inadequate reimbursement, market forces that drive up costs, and maldistribution of clinical services. In improving their ability to manage pain, professionals must understand the difference between pain and suffering, acute and chronic pain, and the sensory and emotional aspects of pain. Guiding principles include Church teaching and ethical principles, such as patient self-determination, holistic care, the principle of beneficence, distributive justice, and the common good. Pain management strategies that will be instrumental in formulating effective responses to these problems include expanding professional and community education, affording pain funding priority, establishing institutional policies and protocols, forming clinical teams, encouraging hospice and home care, and requiring accreditation in pain and symptom management.

Attitude of Health Personnel↗
PubMed2000

[Is terminal sedation active euthanasia?].

In order to be able to discuss the issue of whether or not terminal sedation is, or may be conceived of as, a form of help in dying, one needs to be very clear as to the meaning of the terms "help in dying" and "terminal sedation". In this article, we suggest what we take to be detailed and precise definitions of the two forms of voluntary help in dying--euthanasia and physician-assisted suicide. Our definitions (interpretations) basically draw on the Dutch experience and understanding. The Dutch approach implies that acts of abstention, i.e., withholding and withdrawing treatment, and pain and symptom treatment with possible life-shortening effect, including terminal sedation, are to be considered "normal medical practice". Furthermore, death is seen by almost all parties as having natural causes in all of these acts. We also suggest that "palliative sedation" should substitute the expression "terminal sedation". Furthermore, we discuss on what grounds this treatment strategy may be induced, including a presentation of criteria and guidelines that must be met; the issue of documentation of the strategy; palliative sedation in the light of the ethical principle of double effect; and in what way euthanasia could be concealed as palliative sedation. In closing, we comment briefly on the phenomenon of large differences between published cohorts with regard to the frequency of use of palliative sedation. This treatment strategy is open to be challenged both clinically and ethically, and all parties would benefit from a continuous debate over the legitimacy of, and the clinical need for, palliative sedation.

Attitude of Health Personnel↗