Professional Documents
Culture Documents
Ethics in Critical Care
Ethics in Critical Care
Ethics in Critical Care
Need for
medical
ethics
CMC Vellore
What is the need for medical ethics?
The practice of medicine and the
Ethics in
practice of ethics are inseparable.
Critical Care
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
Need for latter.
medical
ethics
CMC Vellore
What is the need for medical ethics?
Need for
medical
ethics
What is the need to discuss medical
CMC Vellore
ethics now?
Ethics in The foundational principals of ethical
Critical Care health care are under siege
– Hippocratic tradition challenged as
being:
• paternalistic
• anachronistic
• absolutist
• no focus on primary prevention
What about
Hippocrates?
What is the need to discuss medical
CMC Vellore
ethics now?
Ethics in Shifts in the traditional moral grounds of
Critical Care 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
What is the need to discuss medical
CMC Vellore
ethics now?
Ethics in Shifts in the traditional moral grounds of
Critical Care 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
Need for of 1956)
medical
ethics
A new ethical code for health care in the
CMC Vellore
21st century?
The
philosophical
underpinnings of
medical ethics
CMC Vellore
ETHICAL THEORIES
Ethics in TELEOLOGY (Telos = goal)
Critical Care – 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
PROBLEMS WITH THESE
CMC Vellore
MODELS
Ethics in Deontology
Critical Care – 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
The
philosophical – Your values may conflict with the
underpinnings of
medical ethics
action needed
CMC Vellore
RECONCILING THE TWO
Ethics in SEQUENTIAL MODEL
Critical Care
– What is the right thing to do in this
instance?
– What would be the consequences?
Additional ethical principles
Motives-
Action-
Consequences-
Situation
CMC Vellore
ETHICAL PRINCIPLES
Ethics in Autonomy: Respect for an individual’s
Critical Care 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
The Principles impaired autonomy.
of medical
ethics:
Autonomy
CMC Vellore
ETHICAL PRINCIPLES
Ethics in Beneficence: This refers to the
Critical Care 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
The Principles – Negligence
of medical
ethics: – Misconduct
Do good
Do no harm
CMC Vellore
ETHICAL PRINCIPLES
Justice: This refers to the need to treat all
Ethics in people equally and fairly
Critical Care 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
The Principles
of medical
We should strive to provide some decent
ethics: minimum level of health care for all citizens,
Distributive regardless of ability to pay
justice
CMC Vellore
CONFLICTING PRINCIPLES?
The Principles
of medical ethics
THE RELATION BETWEEN
CMC Vellore
LAW AND ETHICS
Ethics in Ethical values have often been
Critical Care 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
The Multi Layered Approach
CMC Vellore
Patient Preferences
Contextual
Ethics in
features:
Critical Care
legal,
social,
family, Medical
Goals
economic
societal Quality of
life issues
The ethicist
as a hedge
Case history
The family’s
wish
CMC Vellore
Intensive dilemma in intensive care
Follow up of
action plan
CMC Vellore
Conversations with Mr. P
Ethics in Knew of his prognosis
Critical Care Wished to live
Agreed to the tracheostomy
Agreed to try hard to get off the
ventilator
Soon realized this was not possible
Began 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
Further conversations with
CMC Vellore
Mr. P
Ethics in Asked to be sent home to die
Critical Care
surrounded by his family
Not possible
I suggested his family be brought
here
List of 15 names of 90 family
members produced
Truth telling is
never easy
CMC Vellore
Of death and dying
Acknowledged a good life
Ethics in Felt at peace with his maker
Critical Care 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
Confronting
ones fears of Family finalized many issues, said their goodbyes
death
CMC Vellore
The final ethical review
Wednesday
CMC Vellore
The aftermath
Ethics in Mr. P’s death affected everyone involved
Critical Care 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
Ethical situations
dilemmas at
the end of
life
CMC Vellore
Lets also remember
Ethics in Medicine is about : “Can we?”
Critical Care
Ethics is about: “Should we?”
The ethicist
as a hedge
Thank you