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ETHICAL PROBLEMS IN INTENSIVE MEDICINE

4thyear

Hamid Reza Asadi

General Medicine, Group 5
2010-11-30

Many hospital deaths are now preceded by an end-of-life decision,

particularly in the intensive care unit (ICU). Such decisions are often
complex and will be influenced by a host of uncontrolled factors
including personal beliefs, cultural and religious influences, and family
pressure, etc. The taboo nature of death and the sensitive quality of
such decisions has for many years hindered research, but more data are
now becoming available as these issues are increasingly recognized and
discussed.
Western ethicists usually consider that there is no ethical difference
between withholding, the process of refusing further medical therapy
that is not indicated, and withdrawing, the process of reducing and
removing the patient from medical therapy that has no benefit whether
that be dialysis, mechanical ventilation, drugs, etc. Indeed, the same
reasons that justify not starting treatment also justify stopping
treatment. In both cases, the decision concerning the treatment applies
to the immediate future. Hence, in practical terms, using mechanical
ventilation as an example, the decisions not to start mechanical
ventilation or to discontinue mechanical ventilation have the same end
result in the immediate future, i.e. no mechanical ventilation. Despite
the lack of legal or moral difference between withdrawing and
withholding, withholding is often seen as being less difficult, a more
passive action.
Once the decision has been made to start a therapy, withdrawing it can
be seen as giving up on the patient. However, treatments should not
be withheld solely for fear that if started they cannot be withdrawn, as
patients may be denied potentially beneficial therapies. Time-limited
trials of therapy may be useful to establish a patients prognosis. Both
withdrawing and withholding are active decisions that will generally
result in the death of the patient but should not be considered as
murder as it is the underlying disease process that ultimately causes
death. It is not the intention to kill patients but to stop futile therapy as
is demanded by ethical statutes.

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Ethical considerations in the adult and pediatric intensive care unit

(ICU) often involve moments of crisis marked by disagreement over
decisions, such as whether to:
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Resuscitate a patient

Extubate and allow the patient to die

Hasten actively a patient's death

Withhold or withdraw unilaterally so-called futile treatment over

a patient's or family's objections

Allocate limited or expensive resources, such as extracorporeal

membrane oxygenation or the last ICU bed.

The expansion of technology (such as nitric oxide, high-frequency

oscillatory ventilation, and partial liquid ventilation) combined with the
awareness of biologic, economic, and ethical limits to applying that
technology may lead to uncertainty and conflict when faced with our
apparent inability to restore a patient to his or her previous state of
personal well-being. Such questions are important; however, we often
are left with the false impression that ethics only comes into play in
these problematic situations existing at the margins of our technical
skill, rather than in our everyday care of critically ill patients. As such,
ethics becomes identified with an ethics committee or consultant called
only when we have failed to reach an agreed course of actiona
consultation that is unable to provide much insight beyond improved
communication and further conversation because these difficult
situations usually impossible to solve in a straightforward manner. In
the absence of overt conflict or controversy, we may mislead ourselves
in thinking that ethics is either unnecessary or that the requirements of
ethics are easily met. We therefore may fail to see those ethical issues
that exist each and every day in our interactions with patients, families,
and fellow workers in the ICU.

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Accordingly, our consideration of ethical issues in the ICU first and

foremost should involve an examination of the ICU as an ethical
working environment that supports the care of critically ill patients.
The environment in which we work impacts on both who we are and
how we act. It is suggested that every clinical case, when seen as an
ethical problem, should be analyzed by means of four topics. These four
topics are:
1. Medical Indications
2. Patient Preferences
3. Quality of Life
4. Contextual Features
Although the facts of each case differ, these four topics are always
relevant. The topics organize the varying facts of the particular case
and, at the same time, the topics call attention to the moral principles
appropriate to the case.

References
1. Robert M. Veatch, Medical Ethics (Jones and Bartlett Series in
Philosophy)
2. Albert Jonsen , Clinical Ethics: A Practical Approach to Ethical Decisions
in Clinical Medicine, Sixth Edition
3. Lectures from the medical ethics from winter semester 2010/2011

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