Practical bioethics in the care of patients with advanced illness

Abstract

Perhaps no field of medicine faces more ethical dilemmas than palliative care, ranging from age-old questions (such as what constitutes ‘a good death’) to novel dilemmas stemming from technological innovation to a conflict of values in a multicultural context. Failure to identify and resolve these issues can fracture relationships and exacerbate suffering. Precisely because matters of morality are not quantifiable like other areas of medicine—and each person is a moral agent with their own beliefs and values—ethics may appear to be the one aspect of healthcare where everyone (regardless of training or role) possesses the tools to solve problems; in practice, however, it often seems that no one does. This chapter defines ethical dilemmas and equips clinicians with tools to recognize dilemmas that are ethical in nature, and those that only appear to be. Once identified as ethical, a structured approach consciously modelled on clinical assessment ensures that all relevant considerations are taken into account. Through effective communication and thoughtful use of additional resources (such as mediation, family meetings, and second opinions), the dilemma often can be resolved. When this does not occur, ethics consultation plays a valuable role both as prelude and complement to palliative care consultation. In situations where the best response remains unclear—or if clear, impossible to implement—clinicians may experience moral distress, which should be identified, navigated, and optimally prevented through conscious steps.