Ethics in Palliative Care

 8/1/2016  411

 Physicians and nurses encounter difficulties in their practice of palliative Care. They do need a good understanding of ethical principles and precedents.
‘A 60-year-old lady with relapsed ovarian cancer, with ascites and profound dyspnea, is in her terminal stage of disease. She has this disease progression one year after her surgery and six months after chemotherapy. Her husband is a retired 65-year-old teacher with chronic heart disease. The son and daughter stay at distant places and can only visit frequently’.
There are a wide range of medical issues and ethical dilemmas that arise in the provision of palliative care for this lady. It is now realized that a good understanding of medical ethics will contribute to the health professional's decision-making and day-to-day practice of medicine for a terminally ill patient.
Medical ethics is primarily a field of applied ethics, the study of moral values and judgments as they apply to medicine. It is intended to provide guidelines and codes for physicians as for their duty, responsibility and conduct and shares many principles with other health care ethics, such as nursing ethics and bioethics. Historically, it can be traced back to Hippocrates, the ancient Greek physician of 4th century BC. Hippocrates (460-380 BC) and his school of students set themselves apart from other healers of their time by stressing that their professional pursuits were rational and scientific rather than magical or religious. Several medical thinkers have emphasized that a physician should carry ‘a good sense and discretion’.
From the 18th century onwards, medical practitioners adopted the Hippocratic Oath as the rite of passage. Similarly, the guiding principle of nursing profession is known as Nightingale Pledge. These two, for the medical and nursing profession respectively, are enshrined in part as, ‘I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone’, and ‘I will practice my profession with conscience and dignity’.
Major evolution and developments in medical ethics were made since 20th century. The betrayal of scientific medicine's ideals during the Second World War by Nazi doctors, in carrying out inhuman medical practices amounting to torture and killing of innocent prisoners, lead to the Nuremberg trial in 1947. The Nuremberg code was issued and this is considered the basis of modern medical ethics. Treatment of human subjects, informed consent, protecting research subjects from harmful medical experiments were incorporated as laws of the society. These laws and policies are provided by Declaration of Geneva (1948, last modified in 2006) and further incorporated in Declaration of Helsinki (1964, last modified in October 2008). It is the responsibility of all medical practitioners to read these documents and imbibe the stated values.


The foundation of medical ethics is supported by four pillars, namely;

Autonomy - patient has the right to choose or refuse the treatment

Beneficence - a doctor should act in the best interest of the patient

Non-maleficence - first, do no harm

Justice - it concerns the distribution of health resources equitably.

Added to the above four, are two more aspects which form the cornerstones of medical practice:

Dignity - the patient and the persons treating the patient have the right to dignity

Truthfulness and honesty - the concept of informed consent and truth telling

All these together constitute the six values of medical ethics.

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