Ethics in Palliative Medicine

Tetsuro Shimizu

Faculty of Arts and Letters,

Tohoku University,

Kawauchi, Aoba-ku, Sendai 980-0862 Japan


In this session we were concerned with ethical issues that are involved in Palliative Medicine.  Before the three speakers' presentations, Professor Stephen C. Schimpff, a chairperson of the session, gave introductory remarks.  He discussed  Palliative Medicine as an exemplar of the new paradigm for medicine, i.e. holistic care, in comparison with the curative model that has been predominant.  The significant difference between the two models lies in the value to which each model assigns priority, i.e., curative attitude of combatting disease vs. holistic medicine's care for the patient as a human being, etc.  On the basis of Dr. Schimpff's presentation, we can also recognize how research into the ethical aspects of palliative medicine is related to its conception with respect to the new paradigm, for the change of priority of values results in a certain shift of ethical judgements as well.


The first speaker, Dr. Geert H. Blijham, reported the basic facts concerning euthanasia and physician-assisted suicide in the Netherlands, including the fact that the main reason for requesting euthanasia or physician assisted suicide is not the unbearable pain but the unrecoverable lack of human dignity caused by the disease.  He concluded that euthanasia does not exclude good palliative care nor should good palliative care exclude euthanasia.  The question was raised of how to distinguish the patient's request for euthanasia or physician-assisted suicide as an autonomous self-determination that could be granted from the expression of a spiritual problem in the patient that should be cared for.  The speaker replied, first, that the solution of how to care for patients in the last four or five weeks of  their life is certainly different from country to country depending on the culture or tradition, and, secondly, that listening to patients is important.  For patients in personal communication with the physician often express their negative reply to the existential question concerning the meaning of the last four weeks of their life, while there can also be a positive reply depending on the patients'  belief systems or religious backgrounds.  Additional comments included the fact that the discussion concerning the possibility of euthanasia in terms of palliative medicine has started also in other countries, including the U.S. and Belgium, and the observation that people's attitudes sometimes depend on their religious backgrounds, e.g., a reason of allowing euthanasia is derived from a belief in life after death.


The second speaker, Dr. Asato Fukaura, reported the introduction of a standardized do-not- resuscitate order form at his university hospital and its effectiveness in lessening the cases of futile cardiopulmonary resuscitation in patients dying of lung cancer.  He concluded that the introduction of do-not-resuscitate order forms and personal medical directives are useful for the patient's interest.  A participant commented that the notification of disease, which the patient needs for being able to give do-not-resuscitate order appropriately, does not seem sufficient. Then, physicians' and families' negative attitudes towards the notification in Japan became the subject of discussion, including the claim that the average rate of notification of cancer must be much higher in many  Japanese hospitals today than the speaker's data suggests is the case for his hospital.  Nevertheless, the report remains significant in that it represents a model of efforts to promote the new paradigm of medicine in hospitals where the curative model is still predominant.


The last speaker, Dr. Atsushi Asai, reported the extent to which, among Japanese physicians, the patient's wishes, including advance directives, are taken into consideration in medical decisions concerning the end of life.  He showed that the main reason for following advance directives is the patients' right to determine their own medical care, while the main reason for overriding them is the family's wishes to prolong  life, which seemed to be one of the biggest barriers to implementing a competent patient's advance directives towards the end of life.  Concerning the report it was discussed that the family's influence in medical decisions in Japan seems to be somewhat different from that in western countries, but beyond the cultural difference the patient's self-determination, and not the family's will, should have priority.  In order to avoid misunderstanding, it should be noted that also the family, which is involved in the palliative medicine, should be appropriately cared for with respect to the quality of life, and again the patient's good relationship with the family improves the patient's quality of life, so that it is better if the family can be brought to agree with the patient, and the medical staff has to try to bring about harmony between them.  Nevertheless, it never means that they are allowed to prioritize the family's will over the patient's own will.


Through the three reports along with the introductory remarks and discussions, the central points of the ethical issues in palliative medicine became apparent.  Dr. Schimpff concluded that the physician has to have a truthful relationship with patients and to recognize their personal autonomy, so that the physician has to ask them what their needs are and not to put the physician's own values or beliefs over those of the patients.  Those conclusions are consistent with the concept of the holistic approach to medical care he referred to in his introductory remarks.


What I would like to have added to the conclusions is as follows.  There are two main aspects of ethical issues; first, the choice of value among diverse values, which are sometimes incompatible with each other, and, secondly, the process of decision making, which consists mainly of the choice of value.  Euthanasia is thought, at least by people with a positive attitude towards it, to be the choice of death which is more valuable in some cases than a life of suffering, and the choice will never be granted if not based on the patient's autonomous determination. Do-not-resuscitate orders as well as advance directives concern the process of decision making in terms of the patient's self- determination, by which the patient determines the priority among diverse values.


Thus the first aspect concerns the goodness that is aimed at by the chosen medical activities, while the second aspect has to do with the goodness in the process of choosing medical activities. The former goodness should be chosen by the patient, and the latter lies only in the fact that the patient autonomously chooses the former.  Consequently the medical staff should support the competent patient being able to make autonomous decisions through trustful communication with the patient (and with the family as well) and should agree with the patient's choice that the medical staff recognizes as reasonable and consistent.  This implies the process of shared decision making and is one of the most important ethical prescriptions to the medical staff.  As to the case of the patient's incompetency, an ethical prescription could be that the medical staff as well as the family should behave as advocates of the patient, but there was not enough discussion in the present session to examine it in detail.

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