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Abstract

This essay discusses the ethical issues frequently encountered in intensive care. General principles of bioethics are almost globally accepted. In particular, the UNESCO Universal Declaration on Bioethics and Human Rights ensures a universal bioethical framework. However, certain discussions still continue in some speciﬁc application areas such as intensive care – which are affected by cultural, religious, legal, and organizational factors. Therefore, specifying the general principles of bioethics concerning the type of the subject to be analyzed and the nature of the ethical reasoning is essential. The nature of intensive care patients and of the services to be provided may cause issues peculiar to intensive care itself, and common ethical issues may become more complicated in relation to the provision of such services.

This essay, ﬁrst, discusses the causes of ethical issues in intensive care. Thereafter, it explains the nature of the intensive care applications by identifying intensive care and life support systems. On this basis, end of life decisions concerning patients’ preferences , the principle of proportionate treatment (beneﬁt and harm), quality of life, treatment futility, and triage topics will be discussed within the framework of relevant ethical principles.

Introduction

This essay discusses ethical issues frequently encountered in intensive care. General principles of bioethics, which include but are not limited to Beauchamp and Childress’s four principles (Beauchamp and Childress 2009), are almost globally accepted. In particular, UNESCO’s Universal Declaration on Bioethics and Human Rights (UDBHR) ensures a universal bioethical framework. However, certain discussions still continue in some speciﬁc application areas such as intensive care – which are affected by cultural, religious, legal, and organizational factors. Therefore, specifying the general principles of bioethics concerning the type of subject to be analyzed and the nature of the ethical reasoning is essential.

While intensive care services can generally be described as “special medical treatment of a dangerously ill patient, with constant monitoring” (The Oxford Encyclopedic English Dictionary), intensive care units (ICUs) – which are more frequently encountered in literature – are the special departments of the hospitals that are particularly designed and structured to provide such services. The nature of ICU patients and of the services to be provided may, on the one hand, cause issues peculiar to intensive care itself; on the other hand, common ethical issues may become more complex in relation to the provision of such services.

This essay discusses the causes of the ethical issues in intensive care and explains the nature of intensive care applications through the identiﬁcation of intensive care and life support systems. First, a brief history of intensive care is presented, including a description of the issues that arise in intensive care treatment. Next, within the framework of ethical principles and relevant ethical codes, arguments for withholding or withdrawing treatment as an end of life decision are addressed, considering patients’ preferences , the principle of proportionate treatment (beneﬁt and harm), quality of life, treatment futility, and issues in triage.

History And Development: Background Of The Issue

Even though the history of intensive care can be traced to Florence Nightingale, a nurse who formed “monitoring units” for soldiers in a separated area during the Crimean War in the 1850s, supporting the organs or systems that have partially or completely lost their functions or using equipment as ventilators and dialysis machines to replace those nonfunctional parts, occurred only in the 1940s with intensive therapy units. In the late 1950s and early 1960s, the present era of critical care began with automated monitoring of vital signs with alarms, and this care rapidly expanded to allow for additional and reﬁned measurements of patient status (Weil and Tang 2011).

Although the term “intensive care” is used in this text, the terms “intensive care,” “intensive therapy,” and “critical care” might be substituted for each other.

From simple to complex, life support systems are generally used for supporting the patient’s bodily functions or for replacing those functions while the body has a chance to recover. These systems, which temporarily support the vital systems, are removed when the body recovers. For instance, a patient who has overdosed and needs artiﬁcial respiration as a support is expected to start breathing by herself/himself when the effect of the medicine subsides. Even though they have effects during the recovery period, the life support systems mainly aim to support vital functions. In ICUs, intensive care services are mostly provided to the patients with the poorest prognosis, individuals who are at the beginning or end of their lives, and those who need invasive life support the most.

In these situations, taking the patient off of a life support system such as a ventilator, or ceasing to provide resuscitation, kidney dialysis, tube feeding, or intravenous injections that extend life may cause the death of the patient. Therefore, treatment may change from supporting the life of the patient to making rapid end of life decisions and providing the best possible quality of end of life care. Clinicians in these cases face a conﬂict between “saving lives” and “providing relief and support near the time of death.” Furthermore, since many patients in intensive care are not capable of making decisions for themselves, it may be necessary to discuss the purposes of the treatment to be administered with the patient’s family, who are expected to represent the patient’s values and choices (Jonsen et al. 2010; Curtis and Vincent 2010).

Besides the aforementioned ethical issues with reference to end of life decisions, from a bioethical perspective, the just sharing of scarce resources must also be considered. Highly developed life sustaining technologies are expensive and tend to consume excessive resources. Further, they require operation by personnel with advanced expertise, whose time is also shared with other patients in need (Curtis and Vincent 2010). In this sense, pursuant to their responsibility to efﬁciently use medical resources, clinicians might face difﬁcult decisions whether to provide intensive care to a particular patient among many patients with rapidly progressing, life-threatening diseases or which patient among many others in critical condition will beneﬁt most from the scarce resources.

Even though the traditional purposes of intensive care are to reduce morbidity and mortality among the patients in critical condition, to support organ systems for a length of time, and to help patients regain their health, recently developed technologies may lead to different results, such as lives with a questionable quality of life or an undesirable prolonging of the death process (Cook and Rocker 2014; Kompanje et al. 2013).

The idea of “refusing to treat those who are overmastered by their diseases, realizing that in such cases medicine is powerless,” which might be interpreted as recognizing the limits of the power of medicine and limiting the treatment, dates back to the Hippocratic Corpus, which was shaped in the fourth century B.C. In Anglo American culture, the history of making explicit choices to avoid heroic efforts to protect life can be traced at most to the Karen Quinlan Case in 1976 and the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research Report (1978–1983) (Jecker 1991). Although the current amount of comparative international data is insufﬁcient, the limitation of treatments that support life in intensive care with the help of life support systems, thereby gradually delaying death, has become more common and is particularly higher in the USA, Canada, and Northern Europe (Akpınar and Ersoy 2012; Curtis and Vincent 2010).

Ethical Considerations In Withholding And Withdrawing Life-Sustaining Treatments

Due to the aforementioned reasons, the patients, patients’ relatives, and clinicians might sometimes be obliged to make decision regarding forgoing life sustaining treatments. Forgoing life sustaining treatments in intensive care can be done in two ways: through withholding or withdrawing of the life sustaining treatments. These decisions can be made either by the patient herself/himself or the surrogate decision maker or through previously expressed wishes by the patient. On the other hand, it is not always possible to know the wishes of the patient in an intensive care situation; in such cases, clinicians undertake the responsibility to make a decision on behalf of the patient based on his/her best interests (Akpınar and Ersoy 2012).

In this section, the situations in which withholding or withdrawing of the treatment in ICUs can ethically be justiﬁed will be discussed with reference to the patients’ preferences :, treatment beneﬁt or futility, the principle of proportionate treatment (beneﬁt and harm), quality of life, and triage topics within the framework of ethical principles and relevant ethical codes.

It was mentioned that the forgoing of life sustaining treatments can be done in two ways, namely, withholding and withdrawing. Withdrawing treatment is deﬁned as giving up treatments currently underway that were started to support the patient’s life but are judged instead to extend the inevitable death period. It is generally relevant in the treatments involving mechanical ventilation or administration of vasoactive agents. Withholding treatment, on the other hand, means not making an intervention or not engaging in a therapeutic escalation. The most widely known example of withholding treatment is the request “Do not resuscitate” (Vincent 2005).

Whether there is a difference in terms of ethics between withdrawing treatment and withholding treatment has widely been discussed over the years. Thus far, no ethical distinction exists between withdrawing and withholding treatments that the patient refuses or that are deemed to be medically futile. Even though most ethicists and professional organizations accept that no moral difference exists between the two actions, it is stated that some healthcare professionals still do not accept their equivalency in practice (Sprung et al. 2014), possibly arising from psychological, religious, and cultural reasons.

Forgoing life sustaining treatments might become an issue in different circumstances, which will be discussed below.

Patient Refusal Of Life Sustaining Treatments

Patients capable of exercising autonomy have the right to determine what to accept as a beneﬁt or burden in terms of their values and expectations and what type of quality of life they ﬁnd acceptable. Therefore, patients should be given the opportunity to decide the extent of difﬁculty they are willing to tolerate for the extent of beneﬁt (Akpınar and Ersoy 2012).

This is only possible through informed consent. As mentioned in Article 5 of the Convention on Human Rights and Biomedicine (Oviedo Convention), “An intervention in the health ﬁeld may only be carried out after the person concerned has given free and informed consent to it. This person shall beforehand be given appropriate information as to the purpose and nature of the intervention as well as on its consequences and risks. The person concerned may freely withdraw consent at any time.” A similar provision can be found in Paragraph 1 of Article 6 of UDBHR.

Informed consent, which might be deﬁned as permission received through sharing necessary information related to the intervention between the clinician and the patient or surrogate decision makers and making such information clear, includes informed refusal, as mentioned above. An informed, volunteer, and capable patient has the right to refuse (withholding) or to give up (withdrawing) life sustaining treatments.

This right is recognized and explained in detail in two declarations of the World Medical Association (WMA). The Declaration of Venice on Terminal Illness includes the sentences, “The patient’s right to autonomy in decision making must be respected with regard to decisions in the terminal phase of life. This includes the right to refuse treatment….” The Statement on Physician Assisted Suicide also describes that “the right to decline medical treatment is a basic right of the patient and the physician does not act unethically even if respecting such a wish results in the death of the patient.”

Therefore, when a patient refuses treatment, withholding or withdrawing it, even if it is life sustaining treatment, is ethically justiﬁed.

Previously Expressed Wishes

Competent adults have the right to consent to or refuse any medical therapy. However, the difﬁculties of an untreatable disease or the death process might confuse an individual and inhibit her capability to decide. Previously expressed wishes are one of the most basic means to implement the principle of respect for personal autonomy in the ﬁeld of healthcare concerning people who are unable to consent (Akpınar and Ersoy 2012). The best way to protect the personal choices of individuals concerning life-supporting treatments and consequently the right to let patients decide for themselves is a Living Will or Advance Directive, deﬁned as “a written statement detailing a person’s desires regarding future medical treatment in circumstances in which they are no longer able to express informed consent, especially an advance directive” (The Oxford Encyclopedic English Dictionary).

Although UDBHR does not mention previously expressed wishes, Article 9 of the Oviedo Convention explicitly mentions the importance of these wishes: “The previously expressed wishes relating to a medical intervention by a patient who is not, at the time of the intervention, in a state to express his or her wishes shall be taken into account.”

Thus, it is an ethical responsibility of the healthcare professionals to bring the requests of the patient, which were previously declared into action. Withholding or withdrawing life supporting treatments in accordance with these requests is ethically justiﬁed.

Surrogate Decision Making

Since many intensive care patients are not capable of making decisions regarding their treatment, family members become the decision makers on behalf of the patient, and the purposes of the treatment are discussed with these surrogate decision makers, who are expected to represent the patient’s values and choices. In cases where the patient’s preferences related to end of life care are not known, life-sustaining treatment decisions are determined by the surrogate decision makers, who are asked to judge what the patient would choose for himself/herself in the situation based on the patients’ own values. The surrogate decision makers are expected to make a decision in accordance with the patient’s values rather than their own personal values.

If the patient has never been competent (incompetent adult), the decision should be made with the participation and consensus of the surrogate decision makers and the clinicians in accordance with the best interests of the patients concerned.

The decision to withdraw life-supporting treatments for children and newborns who are not capable of making decisions on their own in the pediatric or newborn intensive care unit is made with the consensus of the parents, who are assumed to act in the best interests of the child and the clinician.

Both Article 7 of UDBHR and Article 9 of the Oviedo Convention mention the best interests of persons without the capacity to consent.

Consequently, it is ethically justiﬁed to with-hold or withdraw life-supporting treatment if an informed decision to do so is made by a capable patient, by his/her surrogate decision maker, or through the patient’s advance directive.

Futile Treatment

The aforementioned situations are the ones in which necessary regulations and ethical codes are available regarding the withholding or withdrawal of treatment and in which limiting treatment can be done relatively free of barriers. However, it is not always possible to know a patient’s decision. Some patients have never had the capability to make a decision. Others have not declared any preferences : for future situations, and/or the surrogate decision makers are not capable of making decisions in the patient’s best interests. In such cases, the healthcare professionals might need to make the decision to withhold or withdraw treatment based on the best interest of the patient. In these particular situations, treatment futility might be a guide for the healthcare professionals’ decision within the frame of the decision-making process in which the purposes of the medicine as well as the beneﬁts and burdens are evaluated (Akpınar and Ersoy 2012).

Futile interventions were deﬁned by Schneiderman et al. (1990) in their quantitative approach as interventions that turned out to be nonfunctional in the last 100 cases in the doctors’ own experiences or experiences shared by their colleagues or reported empirical data. Although it was later accepted as physiological futileness, according to Schneiderman, quantitative futility refers to the unlikely chance that a treatment will beneﬁt the patient. It differs from physiologic futility, which measures the outcome achieved, whether likely, by the effect on the patient’s physiology or body parts (Schneiderman and De Ridder 2013). In the qualitative approach on the other hand, for instance, treatments that only help maintain a permanent unconscious condition or treatments that do not end total dependency on intensive care are deﬁned as useless, in other words, futile. When the futility of the treatment is evaluated in terms of the purposes of the medicine, results similar to those of the qualitative approach are obtained as well (Akpınar and Ersoy 2012). In other words, if the suggested or planned treatment does not make it possible to achieve any of the purposes of the medicine (e.g., cure the disease; maintain or improve the quality of life through relief of symptoms, pain, and suffering; promote health and prevent disease; prevent untimely death; improve functional status or maintain compromised status; give education and counseling to patients regarding their condition and prognosis; avoid harm to the patient during care; and provide relief and support near the time of death), namely, if there is no medical indication, treatment is accepted as futile (Jonsen et al. 2010).

The WMA Venice Declaration also supports this view with the statement “The physician must not employ any means that would provide no beneﬁt for the patient.”

Principle Of Proportionate Treatment (Benefit And Harm)

The principle of proportionate treatment may also guide the determination of the futility of treatment. As mentioned in Article 4 of UDBHR, in applying medical practice and associated technologies, direct and indirect beneﬁts to patients and other affected individuals should be maximized, and any possible harm to such individuals should be minimized.

In fact, all medical decisions are based on proportioning the beneﬁt/burden ratios of the treatment. When particular life-supporting treatments are in question, the burdens that will accompany the intervention should be considered along with the beneﬁts to be promised to the patient because extending life might not always provide beneﬁt to the patient (Akpınar and Ersoy 2012).

In principle, if the burdens are difﬁcult for the patient than the beneﬁts to be provided, the decision to not start the treatment or to terminate the ongoing treatment might be justiﬁed. A medical treatment is ethically mandatory to the extent that it is likely to confer greater beneﬁts than burdens upon the patient (Jonsen et al. 2010). If a treatment will cause loss of function, disability, or nonproportional pain, the physician is not obliged to apply such treatment (Beauchamp and Childress 2009). In this regard, Fletcher and Davis deﬁne what to calculate as beneﬁt and loss in detail as follows:

Two beneﬁt types of a treatment can increase the wellbeing of a patient: (a) health beneﬁts – treating the disease in a positive and quantiﬁable way, stopping the disease or decreasing the disease, condition, symptoms or the pain; (b) life quality beneﬁts – adding days or months to the patient’s life, which will satisfy both the patient and the patient’s relatives. Two burden types of the treatment can decrease the wellbeing of a patient: (a) when the treatment does not provide any beneﬁt and increased pain, ache and weakness continues; (b) when the treatment suppresses the life quality of the patient. (Fletcher and Davis 2005)

Although these statements seem very clear, it is important to remember that “beneﬁt” and “harm” are value-laden terms for which there is no single measure, particularly in a pluralistic society.

Quality Of Life Considerations

In addition to many medical treatments such as rehabilitation having the general purpose of improving life quality, essentially it is possible to say medicine serve to increase individuals’ quality of life. Even the goal of palliative care is to achieve the best possible quality of life for patients and their families.

However, whether to consider the quality of life of the patient in making the decision to forgo life-sustaining treatment is one of the fundamental ethical issues of modern medicine. Since the understanding of life quality differs from person to person as every individual has different values, beliefs, experiences, and expectations, it is not possible to deﬁne “life quality” in a single way. Therefore, when someone else makes a life quality deﬁnition on behalf of the patient, discommodities arise since he/she makes the decision in accordance with his/her own values and attitudes. However, it should not be forgotten that the lives extended as a result of the development of the medicine’s capacity to delay death may not be deemed worth by the patients, and the main point to consider in the decision related to life-supporting treatment is the quality of the life desired for the patient, not the quality or the value of that life according to others or the society (Akpınar and Ersoy 2012).

There are opinions that life quality should not be used as a criterion for making decisions on behalf of individuals whose values and choices cannot be known. On the other hand, not making such decisions might compel such individuals to live painful and troublesome lives incompatible with human dignity.

Jonsen et al. (2010) suggest three deﬁnitions that might also be used as a factor for both the evaluation of life quality concerning life-supporting treatments and the determination of proportionate care: (a) Restricted quality of life describes a condition in which a person suffers from severe deﬁcits of physical or mental health. (b) Severely diminished quality of life describes a form of life in which a person’s general physical condition has seriously and irreversibly deteriorated, whose range of function is greatly limited, whose ability to communicate with others is minimal, and who may be suffering discomfort and pain. (c) Profoundly diminished quality of life is an appropriate objective description of the condition in which the patient suffers extreme physical debilitation together with apparently complete and irreversible loss of sensory and intellectual activity (Jonsen et al. 2010).

Since the last two conditions mostly indicate a life quality that is not desired and deﬁned as worse than death, withholding or withdrawing life-supporting treatments might be ethically justiﬁed through evaluation with the principle of proportionate treatment and based on quality of life judgments. To withhold or withdraw life-supporting treatment that is considered to be futile in either the qualitative or quantitative approach – which brings more burden to the patient than beneﬁt and that does not make any meaningful contribution to life quality – is ethically appropriate. In fact, to do otherwise is both a violation of the fair sharing of resources principle and contrary to professional integrity.

Triage

It is suggested that the demand for healthcare, particularly intensive care, will continue to exceed the supply. At present, a large difference exists in the availability of ICU beds worldwide (Sprung et al. 2013).

Furthermore, as mentioned in the Introduction, the expensive and excessive resource consuming nature of life support technologies, including the need for personnel with advanced expertise, makes intensive care resources scarce. Consequently, patient admission and discharge decisions are triage decisions.

The term triage means “the assignment of degrees of urgency to wounds or illnesses to decide the order of treatment of a large number of patients or casualties” (The Oxford Encyclopedic English Dictionary). The purpose of triage is to use medical resources as efﬁciently and effectively as possible, following the idea of doing “the greatest good for the greatest number.”

In 1994, the Society of Critical Care Medicine Ethics Committee published a consensus statement related to the sharing of ICU resources (Society of Critical Care Medicine Ethics Committee 1994). According to this statement, the most important issue regarding triage of intensive care patients is survival and it depends on the medical condition of the patient. Generally, patients with good prognosis are in the forefront of patients with bad prognosis. Patients with equal prognosis should be provided service on a “ﬁrst come, ﬁrst served” basis. Patients with bad prognosis and a low likelihood of beneﬁtting from ICU treatment and patients who will recover either receive ICU service or not are not accepted to ICUs.

This guideline was reviewed in 2013, and consensus was reached for most general and speciﬁc ICU triage principles and recommendations (Sprung et al. 2013). Speciﬁcally, it was suggested that triage decisions “should be based on a sound understanding of the probable outcome of the patient’s illness, the availability of therapeutic modalities, the impact of therapy on outcome, and a judgment of the beneﬁts and burdens of the therapy for the patient, the patient’s family, and society.” Furthermore, triage of critically ill patients that may limit individual patient and physician choices is justiﬁed when (1) the policy is aimed at achieving beneﬁts for individual patients, the healthcare institution, or society, and (2) the policy is announced in advance to notify the public.

The consensus is also in accordance with the UDBHR and Oviedo Convention. Article 10 of UDBHR, related to equality, justice, and equity, mentions that all human beings should be treated justly and equitably. Article 3 of the Oviedo Convention more clearly states that “Parties, taking into account health needs and available resources, shall take appropriate measures with a view to providing, within their jurisdiction, equitable access to healthcare of appropriate quality.”

Therefore, established and publicly informed triage guidelines can ensure equitable access to intensive care resources. Further, international acceptance of these guidelines will ensure equal utilization of resources by all intensive care patients.

Conclusion

Based on the aforementioned considerations, it is ethically justiﬁable to withhold or withdraw life-supporting treatments for patients (1) who are informed of their situation and are capable of exercising autonomy or their previously expressed wishes or who have surrogate decision makers who consider the patients’ values; (2) for whom the treatment is deemed futile; (3) for whom the negative consequences of the treatment are greater than the beneﬁts; (4) whose quality of life is undesirable; (5) for whom it was decided through the appropriate triage mechanisms that there are more preferential patients. Such action may even be considered ethically necessary when other obligations such as professional integrity standards or the duty of justice are considered.

However, terminating treatment does not mean terminating care. Following the decision to withdraw treatment, the central issue becomes palliative care and death with dignity. The World Health Organization deﬁnes palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identiﬁcation and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.” In addition, communication with patients and their families is an important factor when decisions are made for intensive care patients.

In these circumstances, as mentioned in Article 18 of UDBHR, “Professionalism, honesty, integrity, and transparency in decision making should be promoted, in particular declarations of all conﬂicts of interest and appropriate sharing of knowledge.”

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