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

Critical Care – 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
 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?

Ethics in  The problems of health systems are

Critical Care in the last analysis ethical:
– Who will live?
– Who will die?
– Who will get what treatment?
– Who will decide?
– And how?

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
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21st century?

Ethics in While I continue to keep this Oath unviolated,

Critical Care 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,
Need for health care has to be based on sound ethical
medical principles that reflect the reality and needs of
ethics contemporary society
 The philosophical underpinnings
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of medical ethics
Ethics in  ETHICAL THEORIES
Critical Care
 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
 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
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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
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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?

Ethics in Not hierarchical

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 non-
malfeasance

The Principles
of medical ethics
 THE RELATION BETWEEN
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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
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Patient Preferences
Contextual
Ethics in
features:
Critical Care
legal,
social,
family, Medical
Goals
economic
societal Quality of
life issues

Foundational Principles, Type of Ethical

Problem
 CMC Vellore
Lets also remember
Ethics in  Medicine is about : “Can we?”
Critical Care
 Ethics is about: “Should we?”

The ethicist
as a hedge
 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
 CMC Vellore
Encounters in CMC

Ethics in  During the procedure he developed

Critical Care respiratory arrest and was put on life
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
Surely there
is a lesson to
attempts would be futile
be learned
in this?
 CMC Vellore
The ethical dilemma begins
 His family had spent more than 8 lakhs and
Ethics in wanted to remove him off the respirator
Critical Care  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

The family’s
wish
 CMC Vellore
Intensive dilemma in intensive care

Ethics in  He has heard of home respirators and

Critical Care 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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 The ICU doctors know treatment is futile
 There is no longer any money to pay for
Ethics in expensive treatments; the family wish to take
Mr. P off life support
Critical Care
 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
The ethical
 Legal issues
dilemma
 CMC Vellore
What would you do?
Ethics in
Critical Care

THE BUCK STOPS HERE

 The ethics committee’s
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recommendations
Ethics in  Independent review of medical notes and
Critical Care physical condition
 Transfer to Neuro-ICU: try to wean off
respirator
 Hospital bears further costs
 Try to get money from ex-employers
 Explore issue of home respirator
 Talk with patient and family
Clinical  Meet in one month to review situation
ethics
committee
meets
 CMC Vellore
Conversations with the family
 Wife very distressed by Mr. P’s condition and
Ethics in prognosis; fears having to deal with him on
Critical Care 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

Mr. P’s wife

 CMC Vellore
Conversations with the family
Ethics in  Very supportive of mother in law and
Critical Care 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-in-

law: the lawyer
 CMC Vellore
The elusive home ventilator
 Costs 2,00,000 Rs
Ethics in  Needs uninterrupted power supply,
Critical Care 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
Other
developments
 Independent medical review
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and Neuro-ICU efforts
Ethics in  Confirmed diagnosis, prognosis
Critical Care
 Attempts at weaning off
respirator not proving successful

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
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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
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The final ethical review

Ethics in The family met ethics committee

Critical Care
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
 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

Did we do the ‘right’ thing?