Principals of Medical Ethics

Overview

A significant number ICU patients are incapacitated and sedated and therefore unable to enter discussions about treatment.
Relatives and their opinions become more influential.
Several areas such as withdrawing treatment and brain stem death testing and organ donation are particular to ICU.
Modern medical ethics at institutional level is primarily deontological, following the ethics of a set of principles. The priority of each principle in practice depends on the situation and the clinical setting. There are four key principles / duties:

  • Autonomy
  • Beneficence
  • Non- maleficence
  • Justice
Autonomy (self rule) is felt by many to be the over-riding principle in medical ethics. This is significantly impaired or absent in ICU patients and as a result the other three principles come to the fore.
Beneficence (acting for the good of the patient) becomes one of the key duties and this is referred to as (soft) paternalism.
Non-maleficence (doing no harm). Can be a fine balance between harm vs benefit of ongoing treatments and is an important consideration for withdrawal decisions.
Justice (fairness):
Individual patients - similar patients get equal access to care
Distributive justice – fair allocation of resources. This entails rationing which is at odds with beneficence and individual justice.

Rationing

Balances economics and ethics
Defined as:
Withholding care that would be of benefit to the patient
Acting in the interests of others and not the patient
Clinician, not the patient, in control

A small benefit may have a huge cost so be rationed
Decisions on rationing use CEA (cost effective analysis) and QALY (quality adjusted life year)
We use rationing all the time in ICU. In a resource scarce system it is ethical to do so (better to spend what money you have on those with reasonable chance of recovery rather than those with minimal chance).