Læknablaðið - 15.10.1989, Blaðsíða 42

304
LÆKNABLAÐIÐ
reworked their statement in light of the
suggestions from the plenary session before
preparing a final report to the whole group. Each
report was then discussed line by line in two long
plenary sessions to produce the following
statement.
PREAMBLE: ETHICAL BACKGROUND
In caring for patients, physicians, as individuals
and as a profession, should act with integrity in
providing medical treatment within certain norms
of care and concern. Despite widely diverse
national, cultural, religious, and political
traditions four prima facie moral values or
principles summarize these norms (4):
1. Autonomy. All persons have a prima facie
moral obligation to respect each other’s
autonomy insofar as such respect is compatible
with the respect for the autonomy of all affected.
This principle requires respect for patients’
deliberated choices made in accordance with their
own values, consciences, and religious
convictions. Respect for patients’ dignity and
integrity, for honesty, and for promise-keeping
are aspects of respect for autonomy. Respect for
the autonomy of health care professionals is no
less important and no more important than the
respect for the autonomy of their patients.
2. Non-maleficience. All persons have a prima
facie moral obligation not to harm each other.
The infliction or risking of harm to others,
including the risks of medical practice, can only
be justified by the pursuit of other moral values -
principally benefits to patients sufficient to
outweigh the harm.
3. Beneficience. All persons have some moral
obligation to benefit others, to some degree,
including, perhaps even especially, those in need.
The extent and scope of this obligation are,
however, highly influenced by both cultural and
individual interpretation. In any case, health care
providers acknowledge themselves to have a
particular obligations to benefit their patients and
to do so with minimal harm.
4. Justifice. All persons have a prima facie moral
obligation to act justly or fairly to others in the
context of the distribution of scarce resources, in
the context of respecting each other’s rights, and
in the context of obeying morally acceptable laws.
Interpretation of the precise nature and extent of
these obligations is highly dependent on both
cultural and individual perspectives.
These four principles or values do not comprise a
single ethical theory. Indeed, they often conflict
and require interpretation and balancing. The
four principles are given different weight in
different cultures and some cultures would wish
to add additional principles or values (5).
Moreover, substantive disagreements exist within
cultures about both their scope and relative
weights.
Nonetheless, their acknowledgement provides a
valuable cross-cultural basis for medico-moral
analysis, discussion, and decison making.
PART I: FOR DECISIONS INVOLVING
COMPETENT (6) PATIENTS OR PATIENTS
WHO EXECUTED AN ADVANCE
DIRECTIVE BEFORE BECOMING
INCOMPETENT
In the context of the norms of medical practice
summarized in the preamble above, five
guidelines are suggested concerning requests from
competent patients or from incompetent patients
who had competently provided advance
directives, oral or written. These guidelines fall
into three categories.
Guidelines
Regarding refusal og treatment
1. If a competent patient rejects treatment that
the physician believes to be in the patient’s
interests, especially where such treatments are
life-prolonging, the physician should seek to
explore the patient’s reasons for such refusal and
seek to correct any misunderstandings. However,
a physician should not impose treatment if
rejected (even if the treatment is potentially
life-prolonging) and should explore alternatives
that might be acceptable to the patient, including
transfer of the patient to the care of a physician or
institution prepared to respect the patient’s wishes
(7). In all cases including those where a patient’s
refusal of a specific treatment is respected, the
physician and the health care institution have the
obligation to continue to offer supportive care
and treatment for pain and suffering.
2. Where an incompetent patient previously has
given a competent advance directive to refuse
treatment and/or has appointed a representative
to make decisions about refusal of treatment,
such advance directives and decisions should be
respected by physicians and other health care
workers.