Mrs. Swanson was in the recovery room following surgery for an intestinal obstruction. Although disoriented from her anesthesia and in great pain from her operation, she called over and over for pain relief. The recovery room nurse told Mrs. Swanson that the doctor would be by in a while and assess her pain at that time.
Diagnosed with AIDS three years ago, Tom recently developed respiratory failure and wound up in the ICU. An endotracheal tube was inserted for breathing support, and after treatment proved ineffective, Tom could not be weaned from the respirator. He had previously expressed his wish not to be sustained on artificial life support, and he now asked the physicians to withdraw the respirator and allow him to die. Tom developed severe anxiety, but his physician refused to administer sedation during the process of withdrawing the respirator, saying, "I will not euthanize this patient."
What do these scenarios have in common? Each reveals some of the ethical problems associated with treating patients when curing them is no longer the goal. In some instances, this point will come when the patient is terminal, in others when the patient has had a medical procedure but is still in pain.
The art and science of alleviating the suffering of the sick is called palliation, and it's a central goal and duty of medicine. The ways in which healthcare practitioners understand and provide palliation varies quite a bit, as nurses and doctors balance competing moral concerns while caring for patients.
In Mrs. Swanson's case, as in many post-operative situations, the nurse was reluctant to administer sufficient post-operative pain medication. Nurses may be afraid of violating established procedures, and physicians may fear producing addiction in the patient, although short-term medicinal use of these drugs rarely produces true addiction. Establishing an adequate plan for pain management during a pre-operative conversation between Mrs. Swanson and her doctor might have prevented her distress.
The AIDS patient's physician balked because he feared that strong sedatives would hasten or even cause the patient's death. Yet if the doctor intends Tom to experience maximal symptom relief but does not intend to actively bring about Tom's death, the doctor is morally justified in administering the medication. Most ethicists agree that the risk of hastening death is morally acceptable if withholding the medication would cause the patient to suffer.
Improved coordination of care and an emphasis on palliating rather than curing requires healthcare providers to shift their focus from fighting and curing disease to alleviating suffering and maximizing life's quality for the person in pain. Indeed, a healthcare practitioner employing good palliation pays attention to patients' emotional, spiritual, and social needs, an attention that affects the ethical decision-making process. The moral landscape changes when the nurse and doctor realize that they are not trying to cure, but simply trying to minimize pain. Aspects of a quality palliative care program include effectively communicating with patients and their families to determine appropriate goals of treatment in light of the patient's changing condition; sufficient control of pain and other symptoms; a collaborative, multidisciplinary approach to meeting the patient's and family's physical, emotional, psychosocial, and spiritual life.
