Læknablaðið - 15.10.1989, Page 45

LÆKNABLAÐIÐ
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justify continuing life-sustaining medical
treatments, thers is no reason to use those
treatments (*12).
PART III: FOR DECISIONS INVOLVING
PATIENTS WHO ARE NOT NOW AND
NEVER HAVE BEEN COMPETENT
These guidelines address patients who now lack
and have always lacked the capacity to choose for
themselves with regard to life-prolonging medical
treatment. They are patients for whom no
»substituted judgment« can be rendered, as their
present or previous wishes and desires cannot be
known. Within this group two further distinctions
may be useful:
1. Between those who, due to anomaly, illness, or
injury, will never develop decisional capacity in
the future (such as anencephalics, the
permanently unconscious, and the severely and
permanently incapacitated) and those who can be
anticipated, if they survive, to develop that
capacity to varying degrees;
2. Between those who have a natural or agreed
surrogate (e.g., parents or guardian) and those
who lack such a surrogate.
Guidelines
1. Regard for the value of life does not imply an
absolute duty to employ life-prolonging treatment
for non-competent patients. In setting reasonable
limits for such treatment, third person judgments
about quality of life, (13) are inevitable.
Responsible third person quality of life judgments
consider, insofar as possible, how the options
must appear from the perspective of one in the
patient’s condition and determine what would
most generally be thought to count as quality for
most such patients (14).
2. Assessing quality of life of these patients for
purposes of medical decisions involves weighing
the ratio of benefits and burdens (15).
3. In most decisions involving patients in this
category, at least five sets of interests may be
discerned:
a) the patient’s;
b) the surrogate’s or family’s;
c) the physician’s and those of other care givers;
d) the health care institution’s (where continuing
or withholding treatment may have religious,
financial, and legal implications and may
expose it to local or national publicity);
e) society’s (including both the use of economic
resources and the need for research to help
future patients).
Normally, the patient’s interests should be
regarded as paramount. However, difficult moral
dilemmas arise when the patient’s interests are
unclear or clearly conflict with a number of other
interests. Societies differ in their preferences for
mechanisms for arbitrating conflicts in these
difficult cases (e.g., institutional ethics
committee, courts). It is important to remember,
however, that in the cases most commonly
encountered, the various interests are not
necessarily in conflict. Often the patient’s own
interest is integrally interwoven with the interest
of the family and the community. Part of the
physician’s clinical wisdom consists of
responsibly weighing interests and creatively
resolving apparently irreconcilable conflicts.
4. When the patient has a surrogate, the
physician’s obligation to the patient also requires
certain duties toward the surrogate. These
include: a) providing accurate information about
the specific clinical problems; b) being honest; c)
applying skills in effective communication; d)
being willing to answer any questions that are
asked; e) being aware of broader social and moral
implications.
To act in a way that recognizes these duties to the
surrogate is to be worthy of the trust that one
hopes the surrogate will place in the physician, so
that a policy of mutual and shared decision
making may be fostered. When the patient is a
child with an emerging capacity to participate in
the decision-making process, both physician and
surrogate demonstrate respect by responding to
questions and concerns at a level consistent with
the child’s cognitive and moral development.
5. While the physician is required to act in a
trustworthy manner toward the patient and
surrogate, the range of interests that could
conflict (see Part II, 3 above) demands that that
same standard of trustworthiness be translated to
the level of social review and professional peer
relationships. Whatever patterns an individual
medical culture may employ to achieve that
translation of standards, the process will be
enhanced by careful documentation of medical
care to facilitate thoughtful audit. This careful
documentation should include both the careful
recording of management plans and the internal
reasoning that led to them. It should routinely
include both medical evidence and the
applications of principles which logically lead to