Ethics in Critical CarePrathap Tharyan MD, MRCPsych

Professor and Head,Department of Psychiatry

Christian Medical College, Vellore

2nd CME ON CRITICAL CARE MEDICINE

CMC Vellore

Ethics in Critical Care

WHAT IS MEDICAL ETHICS?

Medical ethics refers – chiefly to the rules of etiquette adopted by

the medical profession to regulate professional conduct with each other,

– but also towards their individual patients – and towards society, – and includes considerations of the motives

behind that conduct.

Need for medical ethics

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Ethics in Critical Care

What is the need for medical ethics?

The practice of medicine and the practice of ethics are inseparable.

Every clinical decision invokes an ethical decision as well.

In many instances, the ethical issue may not be readily apparent.

In others conflicts arise between ethical principles and medical decisions, which require the clinician to be well versed with the former in order to guide the latter. Need for

medical ethics

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Ethics in Critical Care

What is the need for medical ethics?

The problems of health systems are in the last analysis ethical:– Who will live?– Who will die?– Who will get what treatment?– Who will decide?– And how?

Need for medical ethics

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What is the need to discuss medical ethics now?

The foundational principals of ethical health care are under siege– Hippocratic tradition challenged as

being:• paternalistic • anachronistic • absolutist• no focus on primary prevention

What about Hippocrates?

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What is the need to discuss medical ethics now?

Shifts in the traditional moral grounds of society in general:– Social and moral upheaval of the 1960’s– Changing expectations of a better educated and

more affluent public– The rise of feminism, consumer activism, civil

rights and participatory democracy– The primacy of individual autonomy over shared

communal values A distrust of technology, authority, and

institutions (corrosion of fiduciary relationship)

Society has changed

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What is the need to discuss medical ethics now?

Shifts in the traditional moral grounds of medicine:– Specialisation, fragmentation,

commercialisation, institutionalisation and depersonalisation of heath care.

– Commercialisation of medical education

– Unethical medical practices Consumer protection act (COPRA) 1986 THE INDIAN MEDICAL COUNCIL ACT (102

of 1956)Need for medical ethics

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A new ethical code for health care in the 21st century?

While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the Art, respected by all men, in all times. But should I trespass and violate this Oath, may the reverse be my lot.”

(The Hippocratic Oath, 5th century B.C)

In a world of health care economics, consumers, clients and service providers, health care has to be based on sound ethical principles that reflect the reality and needs of contemporary society

Need for medical ethics

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Ethics in Critical Care

The philosophical underpinnings of medical ethics

ETHICAL THEORIES DEONTOLOGY (Deon = duty)

– Springs from moral obligations– Actions determined by rightness or

wrongness ( virtue ethics)– The outcome of action is not

important

The philosophical underpinnings of medical ethics

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Ethics in Critical Care

ETHICAL THEORIES

TELEOLOGY (Telos = goal)– Actions determined by their

consequences– Motives less important than the

outcome– Greatest good for the greatest

number – Actions will vary depending on the

situation ( situational ethics)The philosophical underpinnings of medical ethics

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Ethics in Critical Care

PROBLEMS WITH THESE MODELS

Deontology– Values are not universally shared– Do not consequences matter?

Teleology– Greatest good for the greatest

number does not protect minority rights

– Not always possible to predict consequences accurately

– Your values may conflict with the action needed

The philosophical underpinnings of medical ethics

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Ethics in Critical Care

RECONCILING THE TWO

SEQUENTIAL MODEL– What is the right thing to do in this

instance? – What would be the consequences?

Additional ethical principles

Motives- Action-Consequences-Situation

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Ethics in Critical Care

ETHICAL PRINCIPLES

Autonomy: Respect for an individual’s autonomy or ability to make decisions for him/herself

– includes respect for their privacy and confidentiality

– need to provide sufficient information for them to make informed choices

– truth telling– protection of persons with diminished or

impaired autonomy. The Principles of medical ethics: Autonomy

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Ethics in Critical Care

ETHICAL PRINCIPLES

Beneficence: This refers to the tradition of acting always in the patients’ best interest to maximise benefits and minimise harm.

Non-malfeasance: This principle ensures that treatment or research ought not to produce harm– Negligence– Misconduct

The Principles of medical ethics:

Do good

Do no harm

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Ethics in Critical Care

ETHICAL PRINCIPLES Justice: This refers to the need to treat all

people equally and fairly Society uses a variety of factors as a criteria

for distributive justice, including the following: – to each person an equal share – to each person according to need – to each person according to effort – to each person according to contribution – to each person according to merit – to each person according to free-market exchanges

We should strive to provide some decent minimum level of health care for all citizens, regardless of ability to pay

The Principles of medical ethics:

Distributive justice

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Ethics in Critical Care

CONFLICTING PRINCIPLES?

Not hierarchicalAutonomy can conflict with

beneficence In India many people do not know how

to deal with autonomy– Wishes of relatives also important

Autonomy/beneficence can conflict with justice

Need to balance beneficence with non-malfeasance

The Principles of medical ethics

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Ethics in Critical Care

THE RELATION BETWEEN LAW AND ETHICS Ethical values have often been

influenced by and influenced legal doctrine and legal principles are closely related to ethical principles.

Ethical obligations exceed legal duties

Law serves to demarcate the limits of individual autonomy in the interests of society. It also protects the rights of individuals

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Ethics in Critical Care

The Multi Layered Approach

Patient Preferences

Medical Goals

Foundational Principles, Type of Ethical Problem

Contextual features: legal, social, family, economicsocietal Quality of

life issues

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Ethics in Critical Care

Lets also remember

Medicine is about : “Can we?” Ethics is about: “Should we?”

The ethicist as a hedge

Helping patients and their families through difficult times is never easy

Prathap Tharyan MD, MRCPsychProfessor and Head,

Department of Psychiatry

On behalf of the CMC Vellore Clinical Ethics Committee

Case history

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Ethics in Critical Care

The case of Mr. P

A 65 year old retired man was diagnosed to have motor neuron disease 4 years prior to retirement and had become progressively worse

Seen in various ‘corporate’ speciality hospitals- poor prognosis conveyed

Sent to CMC Hospital for a feeding gastrostomy- difficulty swallowing

Bed ridden, could not talk, communicated by writing; fully alert and compos mentis

The makings of an ethical dilemma

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Encounters in CMC

During the procedure he developed respiratory arrest and was put on life support

3 months later the ICU head called for a clinical ethics committee meeting

Failed attempts to wean off respiratorOpinion backed by evidence that

further attempts would be futileSurely there is a lesson to be learned in this?

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Ethics in Critical Care

The ethical dilemma begins

His family had spent more than 8 lakhs and wanted to remove him off the respirator

They knew of the prognosis They had no more money to spend. They owed money for treatment at CMC He had a wife, one grown up son, one married

daughter whose husband is a lawyer and two other smaller children who were studying.

All shared the same opinion about what they wish to do.

They did not express the wish to take him home

The family’s wish

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Intensive dilemma in intensive care

He has heard of home respirators and wished to have one.

Did not wish to die The family and Mr. P had not discussed

these issues with each other

Mr. P’s wish

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Ethics in Critical Care

Not just another day at the office The ICU doctors know treatment is futile There is no longer any money to pay for

expensive treatments; the family wish to take Mr. P off life support

Mr. P wishes to live; wants a home ventilator Where does this come from? Mr. P did not want a tracheostomy There are limited ICU beds and many

potentially treatable people who need these beds

This is a Christian institution with certain values

Conflicting ethical principles: every one of them

Legal issuesThe ethical dilemma

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Ethics in Critical Care

What would you do?

THE BUCK STOPS HERE

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Ethics in Critical Care

The ethics committee’s recommendations

Independent review of medical notes and physical condition

Transfer to Neuro-ICU: try to wean off respirator

Hospital bears further costs Try to get money from ex-employers Explore issue of home respirator Talk with patient and family Meet in one month to review situationClinical

ethics committee meets

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Conversations with the family Wife very distressed by Mr. P’s condition and

prognosis; fears having to deal with him on her own if he worsened

Distressed about lack of adequate medical care in her village in Jharkhand

Would rather kill herself than take him home to manage on her own

Did not want to sacrifice her younger children's’ futures in futile treatments

Rational; distressed; not clinically depressed

Mr. P’s wife

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Ethics in Critical Care

Conversations with the family

Very supportive of mother in law and his own wife

Fully aware of legal issues Was in communication with family

back home, including Mr. P’s son Did not see any other practical

solution Pleaded for help

Mr. P’s son-in-law: the lawyer

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The elusive home ventilator

Costs 2,00,000 Rs Needs uninterrupted power supply,

technical support Family live in a village in Jharkhand Wife not willing to try nursing him on a

ventilator at home Transport home by rail or air not

possible Ambulance journey to Jharkhand also

not feasible Money from employer not forthcoming

Other developments

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Ethics in Critical Care

Independent medical review and Neuro-ICU efforts

Confirmed diagnosis, prognosis Attempts at weaning off

respirator not proving successful

Follow up of action plan

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Ethics in Critical Care

Conversations with Mr. P

Knew of his prognosisWished to liveAgreed to the tracheostomyAgreed to try hard to get off the

ventilatorSoon realized this was not possibleBegan to accept that

– his illness would progress; – that a home respirator was not possible – even if it were, his QOL would be poor

A brave and forthright man

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Ethics in Critical Care

Further conversations with Mr. PAsked to be sent home to die

surrounded by his familyNot possible I suggested his family be brought

hereList of 15 names of 90 family

members produced

Truth telling is never easy

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Ethics in Critical Care

Of death and dying Acknowledged a good life Felt at peace with his maker Feared the moment of death: “ did not want to

choke to death’’ Promise that this would not happen Much more at peace about dying after that Wrote that he was willing to be taken off life

support after his family came Family came on a Monday with return tickets

booked for the following Friday Shifted to a private room with technical support Family finalized many issues, said their goodbyes

Confronting ones fears of death

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Ethics in Critical Care

The final ethical review

The family met ethics committeeAll issues reviewed, documentedMy goodbyeThe sedativeWithdrawal of life supportMr. P, in your death, you taught

us about the sanctity of life

Wednesday

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Ethics in Critical Care

The aftermath

Mr. P’s death affected everyone involved

Contrast with the situation 25 years ago Happens everyday without any ethical

review Withdrawal of life support not the central

issue: was it a good death? Should we publish this and call for

discussion, legal guidance? Guidelines for procedures in similar

situationsEthical dilemmas at the end of life

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Ethics in Critical Care

Lets also remember

Medicine is about : “Can we?” Ethics is about: “Should we?”

The ethicist as a hedge

Did we do the ‘right’ thing?

Thank you