2nd CME ON CRITICAL CARE MEDICINE
Ethics in Critical Care
Prathap Tharyan MD, MRCPsych
Professor and Head,
Department of Psychiatry
Christian Medical College, Vellore
Dr. Abdul-Monim Batiha
CMC Vellore
WHAT IS MEDICAL ETHICS?
Ethics in
 Medical ethics refers
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– 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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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
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What is the need for medical ethics?
 The problems of health systems
Ethics in
in the last analysis ethical:
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–
–
–
–
–
Need for
medical
ethics
Who will live?
Who will die?
Who will get what treatment?
Who will decide?
And how?
are
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What is the need to discuss medical
ethics now?
Ethics in
 The foundational principals of ethical
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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
Ethics in
society in general:
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– 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
Society has
changed
institutions (corrosion of fiduciary
relationship)
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What is the need to discuss medical
ethics now?
 Shifts in the traditional moral grounds of
Ethics in
medicine:
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– 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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Ethics in
Critical Care
Need for
medical
ethics
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
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The philosophical underpinnings
of medical ethics
Ethics in
 ETHICAL THEORIES
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 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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ETHICAL THEORIES
Ethics in
 TELEOLOGY (Telos = goal)
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– 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
The
philosophical
underpinnings of
medical ethics
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
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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
MotivesActionConsequencesSituation
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Ethics in
Critical Care
The Principles
of medical
ethics:
Autonomy
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.
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Ethics in
Critical Care
The Principles
of medical
ethics:
Do good
Do no harm
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
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ETHICAL PRINCIPLES
 Justice: This refers to the need to treat all
Ethics in
Critical Care
people equally and fairly
 Society uses a variety of factors as a criteria for
distributive justice, including the following:
–
–
–
–
–
–
The Principles
of medical
ethics:
Distributive
justice
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
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CONFLICTING PRINCIPLES?
Not hierarchical
Ethics in
Critical Care Autonomy 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 nonmalfeasance
The Principles
of medical ethics
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THE RELATION BETWEEN
LAW AND ETHICS
 Ethical values have often been
Ethics in
influenced by and influenced legal
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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
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Patient Preferences
Contextual
Ethics in
features:
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legal,
social,
family,
economic
societal
Medical
Goals
Quality of
life issues
Foundational Principles, Type of Ethical
Problem
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Ethics in
Critical Care
The ethicist
as a hedge
Lets also remember
 Medicine is about : “Can we?”
 Ethics is about: “Should we?”
Case history
Helping patients and their families
through difficult times is never easy
Prathap Tharyan MD, MRCPsych
Professor and Head,
Department of Psychiatry
On behalf of the CMC Vellore Clinical Ethics
Committee
CMC Vellore
The case of Mr. P
Ethics in
 A 65 year old retired man was diagnosed
Critical Care
to have motor neuron disease 4 years prior
The
to retirement and had become
makings of
progressively worse
an ethical
 Seen in various ‘corporate’ speciality
dilemma
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
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Encounters in CMC
 During the procedure he developed
Ethics in
respiratory arrest and was put on life
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Surely there
is a lesson to
be learned
in this?
support
 3 months later the ICU head called for a
clinical ethics committee meeting
 Failed attempts to wean off respirator
 Opinion backed by evidence that further
attempts would be futile
The ethical dilemma begins
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 His family had spent more than 8 lakhs
Ethics in
Critical Care






The family’s
wish
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
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Intensive dilemma in intensive care
Ethics in
 He has heard of home respirators and
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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
Not just another day at the office
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Ethics in
Critical Care
 The ICU doctors know treatment is futile
 There is no longer any money to pay for





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The ethical
dilemma

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 issues
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What would you do?
Ethics in
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THE BUCK STOPS HERE
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The ethics committee’s
recommendations
 Independent review of medical notes and
Ethics in
physical condition
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 Transfer to Neuro-ICU: try to wean off
Clinical
ethics
committee
meets
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 situation
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Ethics in
Critical Care
Conversations with the family
 Wife very distressed by Mr. P’s condition and
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Mr. P’s wife
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
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Conversations with the family
Ethics in
 Very supportive of mother in law and
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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-inlaw: the lawyer
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Ethics in
Critical Care
Other
developments
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
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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 prognosis
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
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Ethics in
Critical Care
Truth telling is
never easy
Further conversations with
Mr. P
 Asked to be sent home to die
surrounded by his family
 Not possible
 I suggested his family be brought
here
 List of 15 names of 90 family
members produced
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Of death and dying
 Acknowledged a good life
Ethics in
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 Felt at peace with his maker
 Feared the moment of death: “ did not want to




Confronting
ones fears of
death


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
The final ethical review
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Ethics in
The
Critical Care
family met ethics committee
All issues reviewed, documented
My goodbye
The sedative
Withdrawal of life support
Mr. P, in your death, you taught us
about the sanctity of life
Wednesday
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Ethics in
Critical Care
Ethical
dilemmas at
the end of
life
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
situations
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Ethics in
Critical Care
The ethicist
as a hedge
Lets also remember
 Medicine is about : “Can we?”
 Ethics is about: “Should we?”
Thank you
Did we do the ‘right’ thing?