TIPS-ECHO Foundation Course Session Summary

Session 4: Medical Ethics

Dr Gayatri Palat

Four Cardinal Principles of Medical Ethics

The following four principles need to be applied against a background of respect for life and
acceptance of the ultimate inevitability of death:
1. Respect for patient’s autonomy (patient choice)
 An expression of informed choice, preferences and consent.
 Acknowledges the patient’s right to know the diagnosis, details of treatment
offered and the right to refuse treatment
 If the patient does not have the mental capacity then spouse > children >
parents > siblings, can make decisions on patients behalf. The patient may
have nominated a family member as their proxy.
2. Beneficence (do good)
3. Non-maleficence (do no harm)
4. Justice (fair use of available resources)
 Concerns balancing individual needs with those of society when resources are
limited

Ethical principles are useful as a broad guideline for patient care. They should be applied on
an individual basis, with compassion and common sense combined with professional
knowledge and skill. While applying these principles one should communicate well with
patients and carers, taking into consideration their social, religious and cultural background.

When in doubt ask “What if it were me?”

Doctrine of Double Effect

“A single act having two possible foreseen effects, one good and one harmful, is not always
morally prohibited if the harmful effect is not intended.”
Example: Patient with dyspnoea is treated with morphine and midazolam. The intention is to
treat, not harm. The medications which improve the patient’s symptoms may cause
respiratory depression but the benefit outweighs the possible harmful effect.

Advance Directive
A document that states your wishes about what health care you want or do not want when you
reach a state in which you cannot speak for yourself. Advance directives are very useful in
preventing futile treatment and the associated suffering and indignity, when life comes to a
close.

Advance Care discussions should occur early in a life-limiting illness while the patient has
capacity. Decisions about care cannot be made properly when the patient has severe
symptoms. It is important to document all discussions about care planning and review the
decisions when appropriate. Such discussions should be part of the daily work of all
physicians. End of life discussions should never come as a surprise to patients or families.

Limiting Futile Treatment: the intention is to relieve symptoms and allow a natural death
With modern medicine it is now possible to prolong the dying process. The decision to stop
life prolonging or life sustaining treatment has to be taken on an individual basis, taking into
consideration the biological prospects (prognosis) of the patient.

Euthanasia: the intention is to end life

Euthanasia is a deliberate intervention undertaken with the express intention of ending life.
“There are better ways to end suffering than ending life.”
Euthanasia is not:
 Allowing nature to take its course
 Stopping biologically futile treatment
 Stopping treatment when the burdens outweigh the benefits
 Using morphine and other drugs to relieve pain
 Using sedatives to relieve intractable mental suffering in a dying patient (palliative
sedation)

Interacting with Medical Colleagues about Goals of Care

 Maintain good relationships and conversations about end of life care and decision
making. Share current evidence for clinical decisions so that you are not presenting
“your view”.
Example: ASCO guidelines for early advance care discussions
 When you have been asked to see a patient for palliative care ask the patient and
family “What are your expectations of me?”
 When discussing the option of a “natural death” talk about what you can do for the
patient rather than what cannot be done?
 Document your discussion, explanations and agreed goals of care.

Patient Story
32 yr old male with advanced colon cancer having undergone palliative surgery and with no
further treatment options. Inpatient at hospice for management of partial bowel obstruction.
Family request that the diagnosis be kept from him. They asked if he could be referred back
to Medical College for an opinion about further surgery.
Ethical dilemmas:
1. Patient autonomy has not been granted as patient not aware of his diagnosis or
prognosis. Family autonomy has been respected. In Indian culture it is the family who
takes the patient for diagnosis and treatment and the family excise their autonomy.
Sometime the patient may not be aware the disease and prognosis. The family usually
collude with the medical team to hide the information from the patient. In such situation,
we have to consider the family, empathise with them and discuss with them “why it is
important to tell the diagnosis and prognosis to the patient”.
2. Before sending the patient to medical college, we have to find out the harm and
beneficence that can be produced with the referral. Usually a patient with advanced
malignant intestinal obstruction, surgical options may not benefit the patient. It may
add more harm to the patient. We should be aware of the disease status and goals of
care before sending the patient for surgical intervention.
3. Management: Family allowed to express their hopes and fears. Family fully informed
of the patient’s very poor prognosis. Patient died before being transferred to Medical
College.

Excellent resource and starting point for palliative care (and other medical) research:
https://www.equator-network.org
The EQUATOR (Enhancing the Quality and Transparency Of health Research) Network is an
international initiative that seeks to improve the reliability and value of published health
research literature by promoting transparent and accurate reporting and wider use of robust
reporting guidelines.