**Bioethics and Health**

**Chapter 1**

**Provisional chapter**

**The Ethical Duty of Physicians to Strengthen Their Own**

Vaccines are one of the most significant discoveries of humanity and are responsible for saving millions of lives around the world. However, their unquestionable successes are criticized and lead to the refusal of parents to vaccinate their children, which causes severe public health problems. There is an ethical duty to adopt various protective measures for the child population, and doctors are considered as decisive actors to help overcome this war. The vaccination rates among doctors and children are very meager, generating a lot of discussion about the implementation of compulsory vaccination for both groups. Thus, medical ethics and bioethics point out some ways for medical professionals to recognize the imperative need for self-vaccination and their patients' sensitization to vaccination, supporting the persuasion of their colleagues and patients. Moreover, the ethical/bioethical principles of the physician's highest duty to protect the society are anchored in beneficence, not maleficence and justice, and they surpass the autonomy right to vaccine refusal. Also, it is expected that the development and dissemination of altruistic ethical values by the physicians can give significant support in the conquest of the "common good."

**Keywords:** medical ethics, bioethics, vaccination, public health, responsibility,

**The Ethical Duty of Physicians to Strengthen Their** 

**Own Immunization and Childhood Vaccination**

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

*Vaccination is the medical sacrament corresponding to baptism* (Samuel Butler, 1835–1902)*.*

Never in the history of human civilization each person's well-being has been so intrinsically linked to others since plagues and pandemics do not respect national boundaries in a globalized

DOI: 10.5772/intechopen.75716

**Immunization and Childhood Vaccination**

Bruno Rodolfo Schlemper Junior,

and Fernando Hellmann

**Abstract**

moral duty, altruism

**1. Introduction**

http://dx.doi.org/10.5772/intechopen.75716

Vilma Beltrame and Fernando Hellmann

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

Bruno Rodolfo Schlemper Junior, Vilma Beltrame

#### **The Ethical Duty of Physicians to Strengthen Their Own Immunization and Childhood Vaccination The Ethical Duty of Physicians to Strengthen Their Own Immunization and Childhood Vaccination**

DOI: 10.5772/intechopen.75716

Bruno Rodolfo Schlemper Junior, Vilma Beltrame and Fernando Hellmann Bruno Rodolfo Schlemper Junior, Vilma Beltrame and Fernando Hellmann

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.75716

#### **Abstract**

Vaccines are one of the most significant discoveries of humanity and are responsible for saving millions of lives around the world. However, their unquestionable successes are criticized and lead to the refusal of parents to vaccinate their children, which causes severe public health problems. There is an ethical duty to adopt various protective measures for the child population, and doctors are considered as decisive actors to help overcome this war. The vaccination rates among doctors and children are very meager, generating a lot of discussion about the implementation of compulsory vaccination for both groups. Thus, medical ethics and bioethics point out some ways for medical professionals to recognize the imperative need for self-vaccination and their patients' sensitization to vaccination, supporting the persuasion of their colleagues and patients. Moreover, the ethical/bioethical principles of the physician's highest duty to protect the society are anchored in beneficence, not maleficence and justice, and they surpass the autonomy right to vaccine refusal. Also, it is expected that the development and dissemination of altruistic ethical values by the physicians can give significant support in the conquest of the "common good."

**Keywords:** medical ethics, bioethics, vaccination, public health, responsibility, moral duty, altruism

#### **1. Introduction**

*Vaccination is the medical sacrament corresponding to baptism* (Samuel Butler, 1835–1902)*.*

Never in the history of human civilization each person's well-being has been so intrinsically linked to others since plagues and pandemics do not respect national boundaries in a globalized

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

world, and also, the unprecedented scope and speed of these universal challenges require articulated responses from everyone [1]. Nowadays, we live in a global village and to live "well" we are going to depend on our ethical response to the idea of a single world for us all [2]. Globally, vaccines are considered one of the most significant discoveries of medicine due to the enormous reduction in mortality and morbidity of various infectious diseases, including the eradication of smallpox [3], and also considered the most efficient and cheapest medical intervention. The World Health Organization (WHO) goal is that mass campaigns promote, at least, the protection of 95% of the target population of a given community because only then those who could not be vaccinated are going to receive the benefits of the so-called herd immunity. Bill Gates, who is the patron of numerous vaccine research, said: "*It is a matter of the most basic human justice that we do all we can to extend these live-saving drugs throughout the globe"* [4]. It is true that the vaccine is not free from adverse events and it is not always effective although vaccine denials use arguments without any reason to generate a war of lies, expressed as follows: *a lie will go round the world while truth is pulling its boots on* [5]. As a result of these controversies, the scientific literature is rich in issues related to vaccination such as the incomprehensible low vaccination rates of physicians and other health professionals. Also, the discussion on compulsory vaccination of these professionals and children, ethical analyzes on physicians behavior that do not self-vaccinate, do not guide their patients and refuse to attend them. In fact, medical institutions and public health officials around the world are at war with these movements that are considered as significant perpetrators of new outbreaks in many countries. Thus, in the counter-offensive of public officials, laws, in several countries, are making child vaccination compulsory [6] and health institutions are beginning to require influenza vaccination from their health professionals. The success of global vaccination will depend on maintaining the population's trust in immunization programs, public policy makers and health professionals engagement [7], especially, physicians. In this call for war, it is affirmed: *There's a war going on out there—a quiet, deadly war* [8], and therefore, the war is literally on fire. On the one hand, there are parents bombarded by misleading propaganda about vaccine damage by irresponsible movements. On the other side, there are doctors tired of parents who do not wish to vaccinate their children, and then, they are refusing to care for these families. In the midst of this not-so-silent war, there are defenseless children because their parents are more afraid of vaccines than diseases. Moreover, new groups of parents are concerned about their vulnerable children who cannot be vaccinated for medical reasons [8]. Thus, in the middle of the crossroads, one can ask the doctors of the world: in which side of the trench are they? It is in this war zone that one hopes to contribute to the reflection on some ethical, bioethical and legal aspects related to medical autovaccination and child vaccination promotion, with the aim of sensitizing physicians to stand on the moral side of the trench and externalize their ethical values through effective and altruistic actions. We all have to aspire to excellence in what we do, and the current pursuit of excellence as in Aristotle's time is the first ethics objective and this is the moral obligation of every human being and, especially, of the professionals [9]. Epidemics are lurking because flu virus are unpredictable, continually changing and both H5N1 and H7N9 are the possible origins of a new pandemic [10].

in preparation for war. Then, they should use as powerful weapons the strength of their altruistic examples and ethical and bioethics arguments, in daily battles, to convince the forces against children's vaccination. The present chapter aims at discussing applicable ethical and bioethical arguments so that the global community will be the victorious side in the war for

The Ethical Duty of Physicians to Strengthen Their Own Immunization and Childhood Vaccination

http://dx.doi.org/10.5772/intechopen.75716

5

*Para que la convivencia social sea ordenada y fructífera toda persona debe comportarse de acuerdo con* 

There is a health understanding regarding the context influences in which one lives. Thus, health does not mean the same thing for all people because it is guided by cultural, political, religious and scientific values. Actions and care to prevent illnesses prescribed by public health physicians follow health policy guidelines adopted by the government. Thus, such instructions may also be conflicting with the community values and, therefore, they are not entirely supported by the people. Individual health care is characterized by doctorpatient relationship and occurs in the clinical practice since public health focuses on the collective, and its actions emphasize the population health conditions in the prevention of diseases, as well as social, economic and demographic factors that influence health and disease process [11]. The public health goal regards diseases prevention and health promotion to prolong life through the society organized efforts, and then, it operates in four different fields. (1) Health promotion and disease prevention. (2) Risk reduction. (3) Research and (4) Socioeconomic disparities with actions to minimize consequences on health [12]. The public health started more than 100 years ago as an organized field and suffered the influence of several professions [11]. Professions diversity is a real challenge and becomes even more prominent when it aims to turn multiprofessional work into an interdisciplinary practice by taking into account the knowledge of professions involved, and also, by considering the cultural values and population knowledge they serve. Therefore, public health professionals should influence the patients' choices regarding support for therapeutic behaviors or conducts before a specific situation. It is also challenging because may generate ethical conflicts. The professionals' values and population they attend could be different, and professionals need to emphasize the importance of collective actions contained in public policies recommended by governmental institutions rather than actions that prioritize the individual [13]. Often, professionals face, in their daily practice, with ethical dilemmas and their conflicts may be due to the programs they need to develop and are mostly imposed on people without previously discussing their guidelines. Thus, it is up to the public health professionals to convince the community that the programs are beneficial and will achieve the objective of promoting the population's health without causing any individual damages [11]. A clear example is a lack of support to vaccination by the population because they believe that vaccines have more harmful effects than beneficial religious precepts, among others. Many times, the public health professionals need to recommend actions that interfere with people's lives, and therefore, they use the epidemiology knowledge, clinical practice, and guidelines contained in the programs. Undoubtedly, such actions aim to reduce

**2. Public health ethics—implications for health professionals**

*ciertos principios éticos y sociales* (Francesco Torralba, 2016)*.*

vaccination and the common good.

Therefore, if there is a declared war, it will be urgent to identify characters and weapons so that the ethical side of combat will be victorious. Besides favorable public policies, the central characters are health professionals, especially physicians, who are expected to be ethically aware of the need for their immunization against epidemic and pandemic infectious agents, in preparation for war. Then, they should use as powerful weapons the strength of their altruistic examples and ethical and bioethics arguments, in daily battles, to convince the forces against children's vaccination. The present chapter aims at discussing applicable ethical and bioethical arguments so that the global community will be the victorious side in the war for vaccination and the common good.

## **2. Public health ethics—implications for health professionals**

world, and also, the unprecedented scope and speed of these universal challenges require articulated responses from everyone [1]. Nowadays, we live in a global village and to live "well" we are going to depend on our ethical response to the idea of a single world for us all [2]. Globally, vaccines are considered one of the most significant discoveries of medicine due to the enormous reduction in mortality and morbidity of various infectious diseases, including the eradication of smallpox [3], and also considered the most efficient and cheapest medical intervention. The World Health Organization (WHO) goal is that mass campaigns promote, at least, the protection of 95% of the target population of a given community because only then those who could not be vaccinated are going to receive the benefits of the so-called herd immunity. Bill Gates, who is the patron of numerous vaccine research, said: "*It is a matter of the most basic human justice that we do all we can to extend these live-saving drugs throughout the globe"* [4]. It is true that the vaccine is not free from adverse events and it is not always effective although vaccine denials use arguments without any reason to generate a war of lies, expressed as follows: *a lie will go round the world while truth is pulling its boots on* [5]. As a result of these controversies, the scientific literature is rich in issues related to vaccination such as the incomprehensible low vaccination rates of physicians and other health professionals. Also, the discussion on compulsory vaccination of these professionals and children, ethical analyzes on physicians behavior that do not self-vaccinate, do not guide their patients and refuse to attend them. In fact, medical institutions and public health officials around the world are at war with these movements that are considered as significant perpetrators of new outbreaks in many countries. Thus, in the counter-offensive of public officials, laws, in several countries, are making child vaccination compulsory [6] and health institutions are beginning to require influenza vaccination from their health professionals. The success of global vaccination will depend on maintaining the population's trust in immunization programs, public policy makers and health professionals engagement [7], especially, physicians. In this call for war, it is affirmed: *There's a war going on out there—a quiet, deadly war* [8], and therefore, the war is literally on fire. On the one hand, there are parents bombarded by misleading propaganda about vaccine damage by irresponsible movements. On the other side, there are doctors tired of parents who do not wish to vaccinate their children, and then, they are refusing to care for these families. In the midst of this not-so-silent war, there are defenseless children because their parents are more afraid of vaccines than diseases. Moreover, new groups of parents are concerned about their vulnerable children who cannot be vaccinated for medical reasons [8]. Thus, in the middle of the crossroads, one can ask the doctors of the world: in which side of the trench are they? It is in this war zone that one hopes to contribute to the reflection on some ethical, bioethical and legal aspects related to medical autovaccination and child vaccination promotion, with the aim of sensitizing physicians to stand on the moral side of the trench and externalize their ethical values through effective and altruistic actions. We all have to aspire to excellence in what we do, and the current pursuit of excellence as in Aristotle's time is the first ethics objective and this is the moral obligation of every human being and, especially, of the professionals [9]. Epidemics are lurking because flu virus are unpredictable, continually changing

4 Reflections on Bioethics

and both H5N1 and H7N9 are the possible origins of a new pandemic [10].

Therefore, if there is a declared war, it will be urgent to identify characters and weapons so that the ethical side of combat will be victorious. Besides favorable public policies, the central characters are health professionals, especially physicians, who are expected to be ethically aware of the need for their immunization against epidemic and pandemic infectious agents, *Para que la convivencia social sea ordenada y fructífera toda persona debe comportarse de acuerdo con ciertos principios éticos y sociales* (Francesco Torralba, 2016)*.*

There is a health understanding regarding the context influences in which one lives. Thus, health does not mean the same thing for all people because it is guided by cultural, political, religious and scientific values. Actions and care to prevent illnesses prescribed by public health physicians follow health policy guidelines adopted by the government. Thus, such instructions may also be conflicting with the community values and, therefore, they are not entirely supported by the people. Individual health care is characterized by doctorpatient relationship and occurs in the clinical practice since public health focuses on the collective, and its actions emphasize the population health conditions in the prevention of diseases, as well as social, economic and demographic factors that influence health and disease process [11]. The public health goal regards diseases prevention and health promotion to prolong life through the society organized efforts, and then, it operates in four different fields. (1) Health promotion and disease prevention. (2) Risk reduction. (3) Research and (4) Socioeconomic disparities with actions to minimize consequences on health [12]. The public health started more than 100 years ago as an organized field and suffered the influence of several professions [11]. Professions diversity is a real challenge and becomes even more prominent when it aims to turn multiprofessional work into an interdisciplinary practice by taking into account the knowledge of professions involved, and also, by considering the cultural values and population knowledge they serve. Therefore, public health professionals should influence the patients' choices regarding support for therapeutic behaviors or conducts before a specific situation. It is also challenging because may generate ethical conflicts. The professionals' values and population they attend could be different, and professionals need to emphasize the importance of collective actions contained in public policies recommended by governmental institutions rather than actions that prioritize the individual [13]. Often, professionals face, in their daily practice, with ethical dilemmas and their conflicts may be due to the programs they need to develop and are mostly imposed on people without previously discussing their guidelines. Thus, it is up to the public health professionals to convince the community that the programs are beneficial and will achieve the objective of promoting the population's health without causing any individual damages [11]. A clear example is a lack of support to vaccination by the population because they believe that vaccines have more harmful effects than beneficial religious precepts, among others. Many times, the public health professionals need to recommend actions that interfere with people's lives, and therefore, they use the epidemiology knowledge, clinical practice, and guidelines contained in the programs. Undoubtedly, such actions aim to reduce morbidity and mortality; however, they raise ethical questions regarding the means by which results are achieved. Again, it can generate ethical conflicts arising from knowledge scientific dichotomy and community values in which they operate, and thus, ethical precepts must mediate their decisions. Nevertheless, what moral rules are appropriate to public health decisions? Thus, public health, in addition to ensuring communities' health, also recognizes that individuals' health is linked to their lives in the community, and then, their non-appreciation would lead to the failure of all. That makes decisions regarding health protection and maintenance, which obey individuals' rights and duties, communities and populations, a central and profoundly complex task for professionals that justify the use of proper ethical principles for public health [13]. It is necessary to observe the ethical principles contained in the Ethics Code for Public Health and recommended by the Public Health Leadership Society, in 2002, to assist conflicts solution [13]. Therefore, the code has clear guidelines to standardize ethics issues about research and public health. However, it does not guarantee the professionals' skills acquisition. Then, ethical issues in public health must be discussed and studied continuously with the clarity that there will always be something new to add since such a field presents emerging and persistent ethical aspects.

autonomy relates to freedom respect insofar as freedom protects the personal autonomy expression. Autonomy, which can be characterized by different notions and theoretical approaches, generally symbolizes the "self-government." In other words, according to Beauchamp & Childress,

The Ethical Duty of Physicians to Strengthen Their Own Immunization and Childhood Vaccination

http://dx.doi.org/10.5772/intechopen.75716

7

Some people characterize compulsory vaccination as a freedom violation and, therefore, an autonomy respect violation. Thus, for those who uphold the primacy of respect for individual freedom at all costs and situations, the laws that require acts such as compulsory vaccination would be incompatible with personal liberties. Autonomy and freedom cannot be dissociated from individual responsibility regarding issues that affect our neighbor or community since studies are pointing out that individuals who abstain from vaccination are at higher risk of contracting infections and endangering their communities. The State must respect the substantial autonomy of the citizen, especially, in measures that restrict freedom of choice. Therefore, there are cases in which they may be ethically justifiable to be limited to the vaccines for infectious diseases by using utilitarian and consequentialist considerations. Utilitarianism, in the promotion of public health, provides with ethical justification to support compulsory vaccination campaigns even though such a task violates the freedom and respect for individual autonomy. Utilitarianism bases on the idea that actions are right if they produce the best consequences for the highest number of people. John Stuart Mill points to the utility as a criterion that should guide choices of moral actions and aim to the happiness of as many individuals as possible [19]. The utilitarianism, actually, has a wield significant influence on bioethics and health policy, namely to improve human health as much as possible for as long as possible [20]. Other current trends in Bioethics that have emerged in Latin America such as the Bioethics of Intervention defend as morally justifiable the priority of public policies that result in the best collective consequences. However, to justify the restriction of individual freedoms in the name of collective good, the State must include, in the discussion, the magnitude of personal and community risks, the individual's conviction regarding his beliefs, the possible long-term consequences of decision-making, the best available scientific

Any arbitrary decision-making by the State jeopardizes the very sustainability of vaccination policy. In summary, although most analysts believe that mandatory vaccination requirements can be ethically justified, restrictions should only be put into practice after complying with certain conditions to publicly assert the defense of that action [21]. The relevance of ethical considerations in vaccination policies has been increasingly recognized, and the attention to such issues will be essential to the continued success of global vaccination programs in the

*You may choose to look the other way, but you can never say again that you did not know* (William

Initially, it is significant to highlight the references to the *Classic Hippocratic Oath*—*I will keep them from harm and injustice*, the *Modern Hippocratic Oath*—*I will prevent disease whenever I can, for prevention is preferable to cure,* as well as the *Corpus hippocraticum where medical art is present,* 

this is the ability to make consistent choises with the values and goals of each person [18].

evidence and transparency in the decision-making process [21].

public good advance and health promotion [17].

Wilberforce)*.*

**4. The physician's ethical duty to autoimmunity**

The Editorial of Lancet Infectious Disease (January, 2018) warns that this month marks the 500th anniversary of the first attempts to control the plague infectious disease in England. However, the recent outbreak in Madagascar reminds us that it is not only confined to the past and many cases continue to be reported in Africa, the Americas, and Asia [14]. Why? Because public health measures have long been underestimated even though they are the most effective interventions regarding public health protection! Without proactive steps, the response will inevitably be reactive and, hence, some delays will result in some degrees of morbidity and mortality that could have been prevented. Many wealthy nations feel complacent about the distant nature of many of these outbreaks. Thus, it is worth remembering that 2018 will mark another infectious disease milestone: the terrible 1918 Spanish flu pandemic [14, 15]. Obviously, vaccines as a means of controlling harmful effects of epidemics are essential tools for humanity. Therefore, all of us, governments, population, health professionals, and others have the ethical responsibility to adopt these effective actions.

## **3. Vaccination: Between autonomy respect and collective common good**

#### *True solidarity begins where nothing is expected in return* (Antoine de Saint-Exupéry)*.*

The classical and ethical problem of public health—the balance between the individual autonomy respect and need for measures aimed at the common good of collective life—is quickly glimpsed in vaccination policies, especially, in mandatory vaccination policies. The ethical dimension is present in all decision-making and public policy-making processes. In the case of vaccination programs, it will be necessary to identify individual and collective risks involved to assess whether the prevalence or severity of such risks outweighs potential benefits to the mass to suspend personal freedoms [16, 17]. Indeed, the consideration of respect for autonomy, individual freedoms and the ethical perspective of utilitarianism vis-à-vis the collective common good is an essential reflection for decision-making in the face of mass vaccination. Respect for freedom protects the person's possibility to take control of his own life and live values that are significant to him. Respect for autonomy relates to freedom respect insofar as freedom protects the personal autonomy expression. Autonomy, which can be characterized by different notions and theoretical approaches, generally symbolizes the "self-government." In other words, according to Beauchamp & Childress, this is the ability to make consistent choises with the values and goals of each person [18].

morbidity and mortality; however, they raise ethical questions regarding the means by which results are achieved. Again, it can generate ethical conflicts arising from knowledge scientific dichotomy and community values in which they operate, and thus, ethical precepts must mediate their decisions. Nevertheless, what moral rules are appropriate to public health decisions? Thus, public health, in addition to ensuring communities' health, also recognizes that individuals' health is linked to their lives in the community, and then, their non-appreciation would lead to the failure of all. That makes decisions regarding health protection and maintenance, which obey individuals' rights and duties, communities and populations, a central and profoundly complex task for professionals that justify the use of proper ethical principles for public health [13]. It is necessary to observe the ethical principles contained in the Ethics Code for Public Health and recommended by the Public Health Leadership Society, in 2002, to assist conflicts solution [13]. Therefore, the code has clear guidelines to standardize ethics issues about research and public health. However, it does not guarantee the professionals' skills acquisition. Then, ethical issues in public health must be discussed and studied continuously with the clarity that there will always be something

6 Reflections on Bioethics

new to add since such a field presents emerging and persistent ethical aspects.

and others have the ethical responsibility to adopt these effective actions.

**3. Vaccination: Between autonomy respect and collective common good**

The classical and ethical problem of public health—the balance between the individual autonomy respect and need for measures aimed at the common good of collective life—is quickly glimpsed in vaccination policies, especially, in mandatory vaccination policies. The ethical dimension is present in all decision-making and public policy-making processes. In the case of vaccination programs, it will be necessary to identify individual and collective risks involved to assess whether the prevalence or severity of such risks outweighs potential benefits to the mass to suspend personal freedoms [16, 17]. Indeed, the consideration of respect for autonomy, individual freedoms and the ethical perspective of utilitarianism vis-à-vis the collective common good is an essential reflection for decision-making in the face of mass vaccination. Respect for freedom protects the person's possibility to take control of his own life and live values that are significant to him. Respect for

*True solidarity begins where nothing is expected in return* (Antoine de Saint-Exupéry)*.*

The Editorial of Lancet Infectious Disease (January, 2018) warns that this month marks the 500th anniversary of the first attempts to control the plague infectious disease in England. However, the recent outbreak in Madagascar reminds us that it is not only confined to the past and many cases continue to be reported in Africa, the Americas, and Asia [14]. Why? Because public health measures have long been underestimated even though they are the most effective interventions regarding public health protection! Without proactive steps, the response will inevitably be reactive and, hence, some delays will result in some degrees of morbidity and mortality that could have been prevented. Many wealthy nations feel complacent about the distant nature of many of these outbreaks. Thus, it is worth remembering that 2018 will mark another infectious disease milestone: the terrible 1918 Spanish flu pandemic [14, 15]. Obviously, vaccines as a means of controlling harmful effects of epidemics are essential tools for humanity. Therefore, all of us, governments, population, health professionals, Some people characterize compulsory vaccination as a freedom violation and, therefore, an autonomy respect violation. Thus, for those who uphold the primacy of respect for individual freedom at all costs and situations, the laws that require acts such as compulsory vaccination would be incompatible with personal liberties. Autonomy and freedom cannot be dissociated from individual responsibility regarding issues that affect our neighbor or community since studies are pointing out that individuals who abstain from vaccination are at higher risk of contracting infections and endangering their communities. The State must respect the substantial autonomy of the citizen, especially, in measures that restrict freedom of choice. Therefore, there are cases in which they may be ethically justifiable to be limited to the vaccines for infectious diseases by using utilitarian and consequentialist considerations. Utilitarianism, in the promotion of public health, provides with ethical justification to support compulsory vaccination campaigns even though such a task violates the freedom and respect for individual autonomy. Utilitarianism bases on the idea that actions are right if they produce the best consequences for the highest number of people. John Stuart Mill points to the utility as a criterion that should guide choices of moral actions and aim to the happiness of as many individuals as possible [19]. The utilitarianism, actually, has a wield significant influence on bioethics and health policy, namely to improve human health as much as possible for as long as possible [20]. Other current trends in Bioethics that have emerged in Latin America such as the Bioethics of Intervention defend as morally justifiable the priority of public policies that result in the best collective consequences. However, to justify the restriction of individual freedoms in the name of collective good, the State must include, in the discussion, the magnitude of personal and community risks, the individual's conviction regarding his beliefs, the possible long-term consequences of decision-making, the best available scientific evidence and transparency in the decision-making process [21].

Any arbitrary decision-making by the State jeopardizes the very sustainability of vaccination policy. In summary, although most analysts believe that mandatory vaccination requirements can be ethically justified, restrictions should only be put into practice after complying with certain conditions to publicly assert the defense of that action [21]. The relevance of ethical considerations in vaccination policies has been increasingly recognized, and the attention to such issues will be essential to the continued success of global vaccination programs in the public good advance and health promotion [17].

## **4. The physician's ethical duty to autoimmunity**

*You may choose to look the other way, but you can never say again that you did not know* (William Wilberforce)*.*

Initially, it is significant to highlight the references to the *Classic Hippocratic Oath*—*I will keep them from harm and injustice*, the *Modern Hippocratic Oath*—*I will prevent disease whenever I can, for prevention is preferable to cure,* as well as the *Corpus hippocraticum where medical art is present,*  *love for humanity is also present*. The Oath ends with a hope and a threat to the physicians: if he respected this ethical norm, he will maintain a good reputation among all human beings for an eternal time, but if, however, a doctor transgress such oath, it will happen the opposite. All quotations seem to imply the ethical duty that currently applies to the requirements for physicians' vaccination.

functioning as a motivational force for others to adopt similar attitudes. How is the physician supposed to convince his patients if he does not protect himself against preventable infections? When physicians' obligatory vaccination is analyzed in light of the classic bioethical principles some findings support that attitude. Then, Beauchamps and Childress state that there are some moral rules regarding positive beneficence [18]: (a) to protect and defend other people's rights; (b) to prevent others from being harmed; (c) to eliminate conditions that will cause harm to others; (d) to help unsuitable people and (e) to rescue people who are in danger. All these moral rules are against the ethical justification that prevents medical refusal. The utilitarian benefit of mandatory vaccination is to reach the threshold percentage of vaccinated individuals required to achieve the herd immunity, according to Field and Caplan [26]. Regarding the physician's autonomy defense, it would be ethically acceptable if his attitude did not cause harm to himself or others, but the exercise of his autonomy in the present situation diminishes to the extent that the refusal may allow his illness or facilitate the infection spread to others [26]. The Supreme Court of the United States recognized for over 100 years that individuals could be subject to multiple restrictions such as submitting to a mandatory vaccine for the benefit of the "common good. At the same time, it is pointed out that defending autonomy does not only mean having freedom of action and rights but also assume responsibility for the consequences of his acts and omissions [27]. Regarding the principle of justice, the reasoning would be similar to that of autonomy because if the severity of a disease increases the public's interest in getting a universal access to a vaccine, it will also grow against it. Therefore, it raises the justice principle importance as the ethical basis for obligatoriness [26]. The ethical consideration of non-maleficence that addresses the risk of adverse drug-use events [28], should not even be discussed since vaccines benefits are so much higher than damages risks [18]. In summary, it is verified that when the seriousness of the disease is severe, contagiousness is high and the vaccine safety is unquestionable, also, there is a prevalence of interests in beneficence, utilitarianism, justice, and non-maleficence that surpass the respect for individual choice (autonomy) [26]. It allows concluding that for the public health is not significant to know what value must be respected but how they should be weighed

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9

against each other and for the community's benefit.

**4.1. Compulsory vaccination of health care works**

*Knowing is not enough; we must apply. Willing is not enough; we must do* (Goethe)

Health professionals (HCWs) are at increased risk of acquiring vaccine-preventable diseases, and then, the purpose is to protect them from occupational exposure and prevent the spread of infections to susceptible patients. According to several medical institutions, the HCWs should be vaccinated, at least, against influenza (annual), measles, mumps, diphtheria, varicella and pertussis, and also, those potentially at risk of contact with blood and secretions should receive the vaccine against Hepatitis B [29]. Despite these recommendations, studies continue to demonstrate that the goals are far from being achieved and many of them refuse vaccination. In the United States, the vaccination rates of these professionals varied from 13 to 83% [30]. They were less than 50% between 2003 and 2008 [31] and only 61.9% in the 2009–2010 pandemic [32]. Currently, as a result of the adoption of US public policies, more than 200 Health Institutions have turned vaccination into mandatory, and state law-

On the other hand, Thomas Percival's first Code of Medical Ethics (1803) emphasizes the physicians' duties and warns of the responsibility to society and value of their actions in the community. Such responsibility obliges the physician, necessarily, to give up the traditional individual good, "the good of patient," to the "public good," a reality of which Percival was a spokesperson [22]. Also, reinforcing the above view, it should be noted that the Code contains an article that covers the physician's duties with the public, as summarized: *As good citizens, it is the duty of physicians to be ever vigilant for the welfare of the community, … and in regard to measures for the prevention of epidemic and contagious diseases …* Then, the original AMA Code updates also include that physicians have an ethical responsibility to take appropriate measures to prevent the spread of infectious diseases in healthcare facilities [1]. It also emphasizes that *in such situations, physicians have a further responsibility to protect their own health to ensure that they remain able to provide care.* The AMA used to accept religious and philosophical questions in the vaccine negative; however, in 2015, these reasons were withdrawn and remained only as valid the exceptions of medical order [23]. The current US code, approved in 2016, renewed its principles and reaffirmed the ethical commitment regarding public health with an expressive phrase: *A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.*

The most well-known and most influential international code of current medical practice has been the Geneva Declaration, which is adopted by the World Medical Association (WMA) [24]. In the latest modification, in 2017, in addition to the traditional oath to dedicate his life to the service of humanity, for the first time, it addresses the promotion of the physician's selfcare with his health: *I will attend to my own health, well-being …* ethical conduct pertinent to the topic of autovaccines. Therefore, there is no doubt it is an ethical imperative for the physician to be immunized against causal agents of outbreaks, epidemics and pandemics. In modern times, the practice of medicine is inconceivable without the moral responsibility that integrates the medical science itself, present not only in the professional acts performed but also in its omissions [25]. This type of responsibility moral omission is clearly present in situations in which physicians know the benefits of autoimmunization; however, by unjustified failure, they evade their ethical responsibility and do not accept being vaccinated. Thus, vaccination is a gesture of social responsibility of the utmost importance. In the context of social commitments of the physician, it is possible to say that the doctor serves, medicine is a profession and the person who does not serve is not fit to be a physician.

Therefore, the society expects physicians to make commitments to it both as social agents and technicians at the service of humanity, in the form of active solidarity. In this context, not only doctors but every health professional has a moral duty to avoid transmitting diseases preventable by vaccination to their colleagues, family members, and patients. In addition to such ethical duties that corroborate the mandatory vaccination, the most significant justification lies in the exemplary positive attitude physicians convey to their patients and colleagues, functioning as a motivational force for others to adopt similar attitudes. How is the physician supposed to convince his patients if he does not protect himself against preventable infections? When physicians' obligatory vaccination is analyzed in light of the classic bioethical principles some findings support that attitude. Then, Beauchamps and Childress state that there are some moral rules regarding positive beneficence [18]: (a) to protect and defend other people's rights; (b) to prevent others from being harmed; (c) to eliminate conditions that will cause harm to others; (d) to help unsuitable people and (e) to rescue people who are in danger. All these moral rules are against the ethical justification that prevents medical refusal. The utilitarian benefit of mandatory vaccination is to reach the threshold percentage of vaccinated individuals required to achieve the herd immunity, according to Field and Caplan [26].

Regarding the physician's autonomy defense, it would be ethically acceptable if his attitude did not cause harm to himself or others, but the exercise of his autonomy in the present situation diminishes to the extent that the refusal may allow his illness or facilitate the infection spread to others [26]. The Supreme Court of the United States recognized for over 100 years that individuals could be subject to multiple restrictions such as submitting to a mandatory vaccine for the benefit of the "common good. At the same time, it is pointed out that defending autonomy does not only mean having freedom of action and rights but also assume responsibility for the consequences of his acts and omissions [27]. Regarding the principle of justice, the reasoning would be similar to that of autonomy because if the severity of a disease increases the public's interest in getting a universal access to a vaccine, it will also grow against it. Therefore, it raises the justice principle importance as the ethical basis for obligatoriness [26]. The ethical consideration of non-maleficence that addresses the risk of adverse drug-use events [28], should not even be discussed since vaccines benefits are so much higher than damages risks [18]. In summary, it is verified that when the seriousness of the disease is severe, contagiousness is high and the vaccine safety is unquestionable, also, there is a prevalence of interests in beneficence, utilitarianism, justice, and non-maleficence that surpass the respect for individual choice (autonomy) [26]. It allows concluding that for the public health is not significant to know what value must be respected but how they should be weighed against each other and for the community's benefit.

#### **4.1. Compulsory vaccination of health care works**

*love for humanity is also present*. The Oath ends with a hope and a threat to the physicians: if he respected this ethical norm, he will maintain a good reputation among all human beings for an eternal time, but if, however, a doctor transgress such oath, it will happen the opposite. All quotations seem to imply the ethical duty that currently applies to the requirements for

On the other hand, Thomas Percival's first Code of Medical Ethics (1803) emphasizes the physicians' duties and warns of the responsibility to society and value of their actions in the community. Such responsibility obliges the physician, necessarily, to give up the traditional individual good, "the good of patient," to the "public good," a reality of which Percival was a spokesperson [22]. Also, reinforcing the above view, it should be noted that the Code contains an article that covers the physician's duties with the public, as summarized: *As good citizens, it is the duty of physicians to be ever vigilant for the welfare of the community, … and in regard to measures for the prevention of epidemic and contagious diseases …* Then, the original AMA Code updates also include that physicians have an ethical responsibility to take appropriate measures to prevent the spread of infectious diseases in healthcare facilities [1]. It also emphasizes that *in such situations, physicians have a further responsibility to protect their own health to ensure that they remain able to provide care.* The AMA used to accept religious and philosophical questions in the vaccine negative; however, in 2015, these reasons were withdrawn and remained only as valid the exceptions of medical order [23]. The current US code, approved in 2016, renewed its principles and reaffirmed the ethical commitment regarding public health with an expressive phrase: *A physician shall recognize a responsibility to participate in activities contrib-*

The most well-known and most influential international code of current medical practice has been the Geneva Declaration, which is adopted by the World Medical Association (WMA) [24]. In the latest modification, in 2017, in addition to the traditional oath to dedicate his life to the service of humanity, for the first time, it addresses the promotion of the physician's selfcare with his health: *I will attend to my own health, well-being …* ethical conduct pertinent to the topic of autovaccines. Therefore, there is no doubt it is an ethical imperative for the physician to be immunized against causal agents of outbreaks, epidemics and pandemics. In modern times, the practice of medicine is inconceivable without the moral responsibility that integrates the medical science itself, present not only in the professional acts performed but also in its omissions [25]. This type of responsibility moral omission is clearly present in situations in which physicians know the benefits of autoimmunization; however, by unjustified failure, they evade their ethical responsibility and do not accept being vaccinated. Thus, vaccination is a gesture of social responsibility of the utmost importance. In the context of social commitments of the physician, it is possible to say that the doctor serves, medicine is a profession and

Therefore, the society expects physicians to make commitments to it both as social agents and technicians at the service of humanity, in the form of active solidarity. In this context, not only doctors but every health professional has a moral duty to avoid transmitting diseases preventable by vaccination to their colleagues, family members, and patients. In addition to such ethical duties that corroborate the mandatory vaccination, the most significant justification lies in the exemplary positive attitude physicians convey to their patients and colleagues,

*uting to the improvement of the community and the betterment of public health.*

the person who does not serve is not fit to be a physician.

physicians' vaccination.

8 Reflections on Bioethics

*Knowing is not enough; we must apply. Willing is not enough; we must do* (Goethe)

Health professionals (HCWs) are at increased risk of acquiring vaccine-preventable diseases, and then, the purpose is to protect them from occupational exposure and prevent the spread of infections to susceptible patients. According to several medical institutions, the HCWs should be vaccinated, at least, against influenza (annual), measles, mumps, diphtheria, varicella and pertussis, and also, those potentially at risk of contact with blood and secretions should receive the vaccine against Hepatitis B [29]. Despite these recommendations, studies continue to demonstrate that the goals are far from being achieved and many of them refuse vaccination. In the United States, the vaccination rates of these professionals varied from 13 to 83% [30]. They were less than 50% between 2003 and 2008 [31] and only 61.9% in the 2009–2010 pandemic [32]. Currently, as a result of the adoption of US public policies, more than 200 Health Institutions have turned vaccination into mandatory, and state lawmakers are beginning to enact laws requiring the HCWs vaccination. They are backed by the Supreme Court that gave the states the power to impose obligatoriness. Some studies in several European countries have revealed absurdly low rates of vaccination of health professionals of 6.4, 15, 25 and 26.3% [33] and even after nine consecutive years, the highest rate was 56% [34]. Compulsory vaccination in Europe is adopted by a few countries, and even then, for very limited indications. After three decades of official recommendations against influenza, the vaccination rates remained below 30% in Europe (**Table 1**).

**Author Study year HCW/observation Country Vaccination rate**

The Ethical Duty of Physicians to Strengthen Their Own Immunization and Childhood Vaccination

hospitals, tertiary care (>90,000 HCW in 62 studies). Higher in USA and lower in

In 2008, vaccination was a condition of

Russel [83] 1998 Staff of 136 nursing homes in Alberta Canada 29.9% Murray [84] 2000 269 staff of teaching hospital Australia 48% O'Rorke [85] 2001 228 staff of acute-care hospital Ireland 17.5%

2009–2010 (H1N1 pandemic)

Semaille [87] 2006 688 general practitioners France 67.0%

2008: 300 HCW (after information and

The highest vaccination coverage rates were in UK (except Northern Ireland),

The vaccination of HCWs is voluntary

hospital. Federal University of São Paulo

nursing of a university hospital to get vaccinated after adequate operational/

206 Physicians, residents, nurses, paramedics) of three Academic Departments (Infectious Diseases, Pediatrics, Gynecology/Obstetrics) 138 (67%) never been vaccinated

Rehmani [90] 2008–2009 502 hospital health care workers Saudi Arabia 34.4%

2006: 286 HCW; 2007:?

staff, doctors, nurses

Hungary and Romania

educational strategies

promotion actions vaccine)

25 countries <5% in India to 82% in USA 40 studies with <50% vaccinated

http://dx.doi.org/10.5772/intechopen.75716

11

United States 1997–2006: ~35–41% 2008: 98.4%

7.6%

2005–2006: 41.8% 2006–2007: 44.4% 2007–2008: 49.0% 2009–2010: 61.9%

2007: 31% 2008: 55.3%

2007–2008: 13.4–89.4% 2014–2015: 5–54.9%

2010: 92.4% 2011: 95.4%

2010: 15.0% 2011: 15.5% 2012: 7.8%

United States 2004–2005: 35.5%

Uruguay 2006: 24%

Australia 22%

Brazil 3.1%

Brazil 2009: 49.8%

Italy 2009: 33.5%

Europe (17 countries)

Kingdom

Weingarten [80] 1986–1987 Nurses. Housestaff United States 3.5% Cui [81] 1996–1998 Staff of 43 nursing homes Hawaii 38%

25,980 active employees.

employment for all

Canning [86] 2003 Acute-care hospitals, Liverpool United

Haviari [82] 1990–2014 Doctors, nurses, midwives of primary care,

Europe

Babcock [49] 1997–2006

2008

Stewart [32] 2004–2010 HCW

European Centre

Giannattasio [92] 2009

[89]

Quian [88] 2006–2208 Physicians, nurses, and others.

2007–2008 2014–2015

(H1N1)–2012

Seale [39] 2007 Hospitals allied health staff and ancillary

Silveira [91] 2009 64pediatric residents of tertiary general

Vieira [93] 2009–2011 265 nurses, technical nurses, auxiliary

Therefore, it is time to consider the mandatory vaccination policies for these professionals [35, 36]. This recommendation was approved by 63% [37] and by more than 98% of them [36] and the physicians accepted it better than nurses and other professionals [37]. Similarly, reduced numbers of vaccination of such professionals were reported in China and Australia, with less than 5% [38] and 22% [39] of influenza vaccinated professionals, respectively. There are several reasons explaining why these professionals avoid vaccination: (a) do not want vaccination; (b) the vaccine is unnecessary; (c) the vaccine is not effective; (d) it may cause adverse events; (e) it may cause influenza; (f) the risk of contracting the disease is low; (g) inadequate time and place of vaccination and (h) fear or aversion to needles [32]. Then, some motivational factors were identified such as the influence of other employees, managers' performance, incentives for vaccination and vaccine accessibility [33]. Several strategies have been developed in some countries to encourage voluntary influenza vaccination in health professionals (promotional and educational campaigns, reports, immunization follow-up, and recommendations), but none with a significant impact on the overall coverage rate. However, vaccination offer in the workplace has produced a more efficient result than other isolated measures. This comes to the observation that inadequate vaccine time and location were considered as a significant barrier to influenza vaccination, and it was one of the reasons for non-vaccination as reported by up to 59% of health workers [32]. There has been a tendency to recommend and accept more stringent measures such as compulsory vaccination as a result of these alarming numbers for human health [30, 31, 34, 40–44]. It should be added that ethical responsibility does not belong only to health professionals but also to each health institution, so that obligation constitutes a new care standard [45]. Some observational studies concluded that mandatory vaccination against influenza increased the vaccination rates to levels around 94% [43].

At the beginning of the nineteenth century, persuasion was considered to be more significant than mandatory. Today, the severity situation demands more extreme and protective measures. Regarding the physicians' refusal for vaccination, more radical measures such as compulsory vaccination and loss of employment have been implemented in several developed countries with the support of the Legal Power, medical entities, and bioethicists [46]. Caplan [47], an American bioethicist, when defending the mandatory vaccination against influenza from health professionals, contrary to the right of autonomy, asks: Rights? The right to infect your patient and the right to cause harm to the people involved in health care? The right to ignore all safety evidence and vaccine efficacy? Or the right to spread unreasonable fear to the public about better protection for babies, pregnant women, the elderly, and vulnerable people against the flu? These rights? It is time to put the patient's priority interest and recognize the professional duty by making vaccination of health professionals against influenza mandatory [41]. The main argument in favor of compulsory vaccination regards codes of The Ethical Duty of Physicians to Strengthen Their Own Immunization and Childhood Vaccination http://dx.doi.org/10.5772/intechopen.75716 11

makers are beginning to enact laws requiring the HCWs vaccination. They are backed by the Supreme Court that gave the states the power to impose obligatoriness. Some studies in several European countries have revealed absurdly low rates of vaccination of health professionals of 6.4, 15, 25 and 26.3% [33] and even after nine consecutive years, the highest rate was 56% [34]. Compulsory vaccination in Europe is adopted by a few countries, and even then, for very limited indications. After three decades of official recommendations against influenza,

Therefore, it is time to consider the mandatory vaccination policies for these professionals [35, 36]. This recommendation was approved by 63% [37] and by more than 98% of them [36] and the physicians accepted it better than nurses and other professionals [37]. Similarly, reduced numbers of vaccination of such professionals were reported in China and Australia, with less than 5% [38] and 22% [39] of influenza vaccinated professionals, respectively. There are several reasons explaining why these professionals avoid vaccination: (a) do not want vaccination; (b) the vaccine is unnecessary; (c) the vaccine is not effective; (d) it may cause adverse events; (e) it may cause influenza; (f) the risk of contracting the disease is low; (g) inadequate time and place of vaccination and (h) fear or aversion to needles [32]. Then, some motivational factors were identified such as the influence of other employees, managers' performance, incentives for vaccination and vaccine accessibility [33]. Several strategies have been developed in some countries to encourage voluntary influenza vaccination in health professionals (promotional and educational campaigns, reports, immunization follow-up, and recommendations), but none with a significant impact on the overall coverage rate. However, vaccination offer in the workplace has produced a more efficient result than other isolated measures. This comes to the observation that inadequate vaccine time and location were considered as a significant barrier to influenza vaccination, and it was one of the reasons for non-vaccination as reported by up to 59% of health workers [32]. There has been a tendency to recommend and accept more stringent measures such as compulsory vaccination as a result of these alarming numbers for human health [30, 31, 34, 40–44]. It should be added that ethical responsibility does not belong only to health professionals but also to each health institution, so that obligation constitutes a new care standard [45]. Some observational studies concluded that mandatory vaccination against influenza increased the vaccination rates to levels around 94% [43].

At the beginning of the nineteenth century, persuasion was considered to be more significant than mandatory. Today, the severity situation demands more extreme and protective measures. Regarding the physicians' refusal for vaccination, more radical measures such as compulsory vaccination and loss of employment have been implemented in several developed countries with the support of the Legal Power, medical entities, and bioethicists [46]. Caplan [47], an American bioethicist, when defending the mandatory vaccination against influenza from health professionals, contrary to the right of autonomy, asks: Rights? The right to infect your patient and the right to cause harm to the people involved in health care? The right to ignore all safety evidence and vaccine efficacy? Or the right to spread unreasonable fear to the public about better protection for babies, pregnant women, the elderly, and vulnerable people against the flu? These rights? It is time to put the patient's priority interest and recognize the professional duty by making vaccination of health professionals against influenza mandatory [41]. The main argument in favor of compulsory vaccination regards codes of

the vaccination rates remained below 30% in Europe (**Table 1**).

10 Reflections on Bioethics



from 3000 to 49,000 deaths are attributed to influenza each year, and influenza vaccination is

The Ethical Duty of Physicians to Strengthen Their Own Immunization and Childhood Vaccination

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13

The leading US medical organizations *(*Immunization Action Coalition) signed a document entitled *First Do No Harm: Mandatory Influenza Vaccination Policies for Healthcare Personnel, Help Protect Patients* [53]. This document was signed by medical leader organizations and additional professions groups claim that mandatory influenza vaccination for all healthcare personnel is imperative! Refer to the position statements of these medical organizations to guide and implementing a mandatory influenza vaccination policy at healthcare institution or medical setting. Then, the following conclusions can be drawn from these data: (1) the arguments in favor of compulsory vaccination against influenza from health workers to patients' safety are ethically, scientifically and financially attractive; (2) the misconceptions and lack of knowledge about influenza vaccines are persistent barriers to a better coverage among health professionals; (3) education alone has not been sufficient and (4) successful programs require the use of multiple strategies including training, incentives, accountability and a strong com-

According to Comte (1798–1857), altruism is the tendency or inclination of an instinctive nature that incites the human being to concern with others, and it is one of the significant reference points for the choice of values in bioethical deliberation. The book Bioethics refers that the technical and biological term for people who take care of others, without thinking about themselves, is altruism and there is a moral sense allowing humans to do that. It is a metaphor—it does not necessarily mean the altruism that one refers when speaking of a right person [55]. Altruist people can assess different or changing situations and it is an act performed in the best interest of others and also for them. Therefore, human beings need the capacity to respond to such changes, especially those developed by other persons. The evolutionary theory offers the altruism origin explanation and other moral sentiments. Thus, social animals such as humans require the ability to help each other and, at the same time, reduce conflicts within the group. Then, persons that take their obligations with others seriously are more stable, work together in harmony and such patterns of behavior result from biological evolution [55]. On the other hand, it is understood that morality is an important dimension of ethics and to do what I must to others is part of living well and a characteristic of this century is the increasing recognition of each one's moral obligations to others [56]. According Appiah,

honor is one important cause of the moral progress, in guiding us to a better future.

Selfishness is an opposed concept in which the unlimited love that a person feels for himself leads to serve his interests exclusively. It is a conduct characterized as narcissistic ethics [57]. The issue on "how to be good" differs from "how to do it right" since the good nature is the obligation to do all the good we can, considering all things and making the world a better place because being good is essential for ethics. These individual obligations and responsibilities constitute the moral arguments of our human condition to do good [58]. The central point of compulsory vaccination can be supported by people's moral responsibility, in the

a significant method for reducing flu deaths [52].

**4.2. The pursuit of altruistic attitude of doctors**

*Advice is judged by results, not by intentions* (Cicero)*.*

mitment at all levels [54].

**Table 1.** Flu vaccine coverage in health care works (HCW) reported in the literature\* .

ethics of physicians, nurses, nursing assistants, social workers, pharmacists and other health professionals who declare that patients' interests should prevail over professionals' ojnes [47]. The first ethical principle is not causing harm to others and, therefore, professionals must be vaccinated compulsorily since maleficence, whether intentional or not, is unacceptable [48]. Secondly, they must protect defenseless and vulnerable patients. In conclusion, mandatory vaccination against influenza should prevail over personal choices and, even more importantly, it is ethically significant that physicians give good examples when vaccinating as they can influence their patients' vaccination [47]. An increasing number of US hospitals require health professionals to vaccinate against influenza and other infectious diseases to protect their patients [49]. Therefore, obligatoriness should be preceded by a comprehensive educational program for current professionals, and new HCW understand that vaccination is an indispensable condition of employment [31, 46]. Vaccination is considered as a privilege and not an obligation, and those who do not wish to have the vaccine should consider the consequences of this act and know how to bear it, remembering that preserving public welfare and reducing diseases are important values [50]. Mandatory influenza vaccination for all healthcare works is ethical, just, and necessary to improve patient's safety and it is a crucial step in efforts to reduce healthcare associated with influenza infections [51]. When a person starts working at a healthcare institution as a professional, he has certain obligations and one of them is to take precautions to protect patients against infections. Only in the United States, from 3000 to 49,000 deaths are attributed to influenza each year, and influenza vaccination is a significant method for reducing flu deaths [52].

The leading US medical organizations *(*Immunization Action Coalition) signed a document entitled *First Do No Harm: Mandatory Influenza Vaccination Policies for Healthcare Personnel, Help Protect Patients* [53]. This document was signed by medical leader organizations and additional professions groups claim that mandatory influenza vaccination for all healthcare personnel is imperative! Refer to the position statements of these medical organizations to guide and implementing a mandatory influenza vaccination policy at healthcare institution or medical setting. Then, the following conclusions can be drawn from these data: (1) the arguments in favor of compulsory vaccination against influenza from health workers to patients' safety are ethically, scientifically and financially attractive; (2) the misconceptions and lack of knowledge about influenza vaccines are persistent barriers to a better coverage among health professionals; (3) education alone has not been sufficient and (4) successful programs require the use of multiple strategies including training, incentives, accountability and a strong commitment at all levels [54].

### **4.2. The pursuit of altruistic attitude of doctors**

ethics of physicians, nurses, nursing assistants, social workers, pharmacists and other health professionals who declare that patients' interests should prevail over professionals' ojnes [47]. The first ethical principle is not causing harm to others and, therefore, professionals must be vaccinated compulsorily since maleficence, whether intentional or not, is unacceptable [48]. Secondly, they must protect defenseless and vulnerable patients. In conclusion, mandatory vaccination against influenza should prevail over personal choices and, even more importantly, it is ethically significant that physicians give good examples when vaccinating as they can influence their patients' vaccination [47]. An increasing number of US hospitals require health professionals to vaccinate against influenza and other infectious diseases to protect their patients [49]. Therefore, obligatoriness should be preceded by a comprehensive educational program for current professionals, and new HCW understand that vaccination is an indispensable condition of employment [31, 46]. Vaccination is considered as a privilege and not an obligation, and those who do not wish to have the vaccine should consider the consequences of this act and know how to bear it, remembering that preserving public welfare and reducing diseases are important values [50]. Mandatory influenza vaccination for all healthcare works is ethical, just, and necessary to improve patient's safety and it is a crucial step in efforts to reduce healthcare associated with influenza infections [51]. When a person starts working at a healthcare institution as a professional, he has certain obligations and one of them is to take precautions to protect patients against infections. Only in the United States,

**Author Study year HCW/observation Country Vaccination rate**

acute-care reference center (1300 bed). Despite almost a decade of efforts, the vaccination coverage rates was very low

an influenza immunization policy had national recommendations for vaccination of HCW against influenza in 2014/2015. The survey was by email for the national immunization programme under the

Spain 50.7%

China 5.0%

United States 77.3%

26 countries (Europe Region)

.

Italy Physicians: 30%

Nurses: 11% Other clinical personnel: 9%

From 2.6% to 99.5%; median 29.5%.

The majority of countries reported rates <40%

2017–2018: 63.9%

79.0%

England 2016–2017: 61.8%

Domínguez [94] 2012 1749 primary HCW (family physicians,

Alicino [34] 2013–2014 Teaching hospital in Genoa, tertiary adult

Song [38] 2013–2014 All HCWs providing direct patient care at

Jorgensen [95] 2014–2015 All member states, except Denmark, with

Black [96] 2014–2015

Public Health England [97]

12 Reflections on Bioethics

\*

2015–2016

2016–17 2017–18

Adapted from Weber and Rutala [29].

pediatricians, nurses)

10 healthcare institutions.

Ministries of Health

594,700 HCW 641,600 HCW

**Table 1.** Flu vaccine coverage in health care works (HCW) reported in the literature\*

Health Care Personnel: 2014–2015: 1.914 2015–2016: 2.258

#### *Advice is judged by results, not by intentions* (Cicero)*.*

According to Comte (1798–1857), altruism is the tendency or inclination of an instinctive nature that incites the human being to concern with others, and it is one of the significant reference points for the choice of values in bioethical deliberation. The book Bioethics refers that the technical and biological term for people who take care of others, without thinking about themselves, is altruism and there is a moral sense allowing humans to do that. It is a metaphor—it does not necessarily mean the altruism that one refers when speaking of a right person [55]. Altruist people can assess different or changing situations and it is an act performed in the best interest of others and also for them. Therefore, human beings need the capacity to respond to such changes, especially those developed by other persons. The evolutionary theory offers the altruism origin explanation and other moral sentiments. Thus, social animals such as humans require the ability to help each other and, at the same time, reduce conflicts within the group. Then, persons that take their obligations with others seriously are more stable, work together in harmony and such patterns of behavior result from biological evolution [55]. On the other hand, it is understood that morality is an important dimension of ethics and to do what I must to others is part of living well and a characteristic of this century is the increasing recognition of each one's moral obligations to others [56]. According Appiah, honor is one important cause of the moral progress, in guiding us to a better future.

Selfishness is an opposed concept in which the unlimited love that a person feels for himself leads to serve his interests exclusively. It is a conduct characterized as narcissistic ethics [57]. The issue on "how to be good" differs from "how to do it right" since the good nature is the obligation to do all the good we can, considering all things and making the world a better place because being good is essential for ethics. These individual obligations and responsibilities constitute the moral arguments of our human condition to do good [58]. The central point of compulsory vaccination can be supported by people's moral responsibility, in the understanding that self-vaccination of health professionals and other members of the community will also help in the protection of others. It is possible to make an analogy with organs donation to exemplify the situation since Singer [59] calls such action as an altruistic act that portrays the human moral obligation to others, especially the less fortunate. This act can be considered an insignificant sacrifice to save or protect another human life [59] and, by analogy, the health professionals' self-vaccination can also be understood as an altruistic action. Altruism can be defined in many ways, and a useful distinction for our purposes is between the behavioral and motivational definitions of the term. Motivational conceptions of altruism are identified with the medical attitude to self-vaccination because they are internal psychological states that produce altruistic behaviors and actions carried out by a person who wishes to contribute to the well-being of another person.

brought many new insights to the thinking about human life, including human moral nature. In the present situation of vaccination, it is worth believing that the act of taking vaccines by

The Ethical Duty of Physicians to Strengthen Their Own Immunization and Childhood Vaccination

http://dx.doi.org/10.5772/intechopen.75716

15

*Parents can't do everything, but when you have the power to prevent something from happening, you* 

Physicians should take advantage of the meetings with patients to educate them on how to minimize health risks and, thereby, fulfill the obligations to promote the patient's well-being and contribute to public health improvement [62]. Ethics is not individual. It is always relational whether in group or collective; therefore, it is possible to affirm that all thinking beings have ethics. Thus, if a person acts for his benefit and causes harm or damage to other people, it can be said that is a wrong attitude, narcissistic ethics or, in other words, an ethics whose value and the principle of solidarity and fraternity are not present [57]. It is the real situation regarding vaccination discussion and the conduct of those who refuse to vaccinate. It is called "Convenience Ethics," which contrasts with the "Ethics of Dignified Collective Life" or "Capital Ethics," which is a life protection ethics of the collectivity and one of the most robust ethical values of our human condition to live in a community [57]. Therefore, aiming at the search for the common good it is possible to justify the need to call the attention to such physicians' ethical commitment, which is anchored in the worldwide concern of reducing the vaccination rates of children. Every single study, on a worldwide scale, highlights that health professionals, especially physicians, are considered by parents as a primary and reliable source of information on childhood vaccination [63–66], and pediatricians and family doctors are more capable of convincing parents to make a decision. It is worth saying that it is the physicians' ethical duty to fulfill such a task by exploring their level of knowledge about vaccines, their underlying values and beliefs about immunization [67], highlighting, above all, the social reach of mass vaccination and possible consequences for other children if all

In the face of a possible conflict and from the ethical point of view, the physician should deliberate with parents to show individual and community benefits such as herd immunity, so that parents can understand the risk that would arise if all mothers had the same negative behavior [68]. Thus, the Spanish bioethicists point out that after the information in the deliberation process, the next step is persuasion as a clinical and ethical resource that cannot be confused with manipulation or coercion because they are unacceptable. According to the circumstances and in the face of common good and autonomy conflict, it is quite ethical to consider that those responsible are ill-informed and it is not morally admissible or respectable to exercise autonomy based on error and irrationality, especially, when such a conduct entails a risk for other people's lives [68]. In other words, physicians should try to persuade resistant parents and remind them that vaccine is not a medicine that only benefits those who use it but also protects the individual against certain diseases, including his family members and community. After these attempts, if the refusal to vaccinate their children persists, physicians may try the

the healthcare workers means helping without expecting any rewards.

**5. The ethical duty of physicians to vaccinate children**

*do it!* (Cheryl Lieck, a mother)

parents refuse to vaccinate them.

Thus, the behavioral definition of altruism, by contrast, focuses exclusively on the costs and benefits of action for the person in question. Many defenders of altruistic action consider altruism as a significant virtue with a combination of reasons in which there is a genuine desire to help others and a desire to improve their quality of life. It is precisely the altruistic sense that one wishes to mobilize and stimulate for the physicians' autovaccination. Yet, by exploring altruism a little more, there is a distinction between restricted and expanded altruism. The first includes only doing good to the closest ones like family and friends, while the second also includes, besides them, strange people. Therefore, self-vaccination medical altruism clearly identifies itself with the expanded form of doing good for others, benefiting physicians, family, and patients. Then, by analogy with the example of organs donation, it is expected that physicians' attitudes towards autovaccination will also expand in these professionals since effective altruism, which has Singer as one of its creators, is a breakthrough in people's ethical behavior. The effective altruism focuses on the attainment of goals, that is, on the vision of consequentialist ethics and as an ethical proposal for the contemporary world [60]. Here, it is reiterated that autovaccination is not an extreme procedure but the attitude is also a good for others, and it is done autonomously for the benefit of strangers. It is also possible to believe that parents who hesitate to vaccinate their children may be motivated by the altruistic action of their doctors and in the exercise of a selfless attitude they will be protecting their families. Effective altruistic actions performed by a large number of people can demonstrate an unimaginable power capable of contributing expressively to the common good ("The Most Good I Can Do"). However, the altruistic motivation is still an open field for investigations as it has not yet been considered in epidemiological studies on vaccination decisions or vaccination projects [61]. Thus, a higher dissemination of information combined with more precise guidelines on altruistic actions (and potentially specific of the vaccine) from health professionals and the general population may leverage towards the objectives of the vaccination policy. Therefore, the same situation regarding organs donation in which attitudes are changing and donations are increasing, altruistic behaviors are identified in large part of the population [59]. When the physician is committed to his work beyond the financial part, he is practicing altruistic attitudes. They are considered ethical virtues that imply a personal commitment and a consistent motivation with the essence of the medical profession, which means they will be at people's service. Of course, wealthy nations will need to decide if they are going to fund healthcare beyond their borders because by now, they will be familiar with the self-interested altruism argument [14]. In conclusion, the best assessment is that the evolutionary biology has brought many new insights to the thinking about human life, including human moral nature. In the present situation of vaccination, it is worth believing that the act of taking vaccines by the healthcare workers means helping without expecting any rewards.

## **5. The ethical duty of physicians to vaccinate children**

understanding that self-vaccination of health professionals and other members of the community will also help in the protection of others. It is possible to make an analogy with organs donation to exemplify the situation since Singer [59] calls such action as an altruistic act that portrays the human moral obligation to others, especially the less fortunate. This act can be considered an insignificant sacrifice to save or protect another human life [59] and, by analogy, the health professionals' self-vaccination can also be understood as an altruistic action. Altruism can be defined in many ways, and a useful distinction for our purposes is between the behavioral and motivational definitions of the term. Motivational conceptions of altruism are identified with the medical attitude to self-vaccination because they are internal psychological states that produce altruistic behaviors and actions carried out by a person who wishes

Thus, the behavioral definition of altruism, by contrast, focuses exclusively on the costs and benefits of action for the person in question. Many defenders of altruistic action consider altruism as a significant virtue with a combination of reasons in which there is a genuine desire to help others and a desire to improve their quality of life. It is precisely the altruistic sense that one wishes to mobilize and stimulate for the physicians' autovaccination. Yet, by exploring altruism a little more, there is a distinction between restricted and expanded altruism. The first includes only doing good to the closest ones like family and friends, while the second also includes, besides them, strange people. Therefore, self-vaccination medical altruism clearly identifies itself with the expanded form of doing good for others, benefiting physicians, family, and patients. Then, by analogy with the example of organs donation, it is expected that physicians' attitudes towards autovaccination will also expand in these professionals since effective altruism, which has Singer as one of its creators, is a breakthrough in people's ethical behavior. The effective altruism focuses on the attainment of goals, that is, on the vision of consequentialist ethics and as an ethical proposal for the contemporary world [60]. Here, it is reiterated that autovaccination is not an extreme procedure but the attitude is also a good for others, and it is done autonomously for the benefit of strangers. It is also possible to believe that parents who hesitate to vaccinate their children may be motivated by the altruistic action of their doctors and in the exercise of a selfless attitude they will be protecting their families. Effective altruistic actions performed by a large number of people can demonstrate an unimaginable power capable of contributing expressively to the common good ("The Most Good I Can Do"). However, the altruistic motivation is still an open field for investigations as it has not yet been considered in epidemiological studies on vaccination decisions or vaccination projects [61]. Thus, a higher dissemination of information combined with more precise guidelines on altruistic actions (and potentially specific of the vaccine) from health professionals and the general population may leverage towards the objectives of the vaccination policy. Therefore, the same situation regarding organs donation in which attitudes are changing and donations are increasing, altruistic behaviors are identified in large part of the population [59]. When the physician is committed to his work beyond the financial part, he is practicing altruistic attitudes. They are considered ethical virtues that imply a personal commitment and a consistent motivation with the essence of the medical profession, which means they will be at people's service. Of course, wealthy nations will need to decide if they are going to fund healthcare beyond their borders because by now, they will be familiar with the self-interested altruism argument [14]. In conclusion, the best assessment is that the evolutionary biology has

to contribute to the well-being of another person.

14 Reflections on Bioethics

*Parents can't do everything, but when you have the power to prevent something from happening, you do it!* (Cheryl Lieck, a mother)

Physicians should take advantage of the meetings with patients to educate them on how to minimize health risks and, thereby, fulfill the obligations to promote the patient's well-being and contribute to public health improvement [62]. Ethics is not individual. It is always relational whether in group or collective; therefore, it is possible to affirm that all thinking beings have ethics. Thus, if a person acts for his benefit and causes harm or damage to other people, it can be said that is a wrong attitude, narcissistic ethics or, in other words, an ethics whose value and the principle of solidarity and fraternity are not present [57]. It is the real situation regarding vaccination discussion and the conduct of those who refuse to vaccinate. It is called "Convenience Ethics," which contrasts with the "Ethics of Dignified Collective Life" or "Capital Ethics," which is a life protection ethics of the collectivity and one of the most robust ethical values of our human condition to live in a community [57]. Therefore, aiming at the search for the common good it is possible to justify the need to call the attention to such physicians' ethical commitment, which is anchored in the worldwide concern of reducing the vaccination rates of children. Every single study, on a worldwide scale, highlights that health professionals, especially physicians, are considered by parents as a primary and reliable source of information on childhood vaccination [63–66], and pediatricians and family doctors are more capable of convincing parents to make a decision. It is worth saying that it is the physicians' ethical duty to fulfill such a task by exploring their level of knowledge about vaccines, their underlying values and beliefs about immunization [67], highlighting, above all, the social reach of mass vaccination and possible consequences for other children if all parents refuse to vaccinate them.

In the face of a possible conflict and from the ethical point of view, the physician should deliberate with parents to show individual and community benefits such as herd immunity, so that parents can understand the risk that would arise if all mothers had the same negative behavior [68]. Thus, the Spanish bioethicists point out that after the information in the deliberation process, the next step is persuasion as a clinical and ethical resource that cannot be confused with manipulation or coercion because they are unacceptable. According to the circumstances and in the face of common good and autonomy conflict, it is quite ethical to consider that those responsible are ill-informed and it is not morally admissible or respectable to exercise autonomy based on error and irrationality, especially, when such a conduct entails a risk for other people's lives [68]. In other words, physicians should try to persuade resistant parents and remind them that vaccine is not a medicine that only benefits those who use it but also protects the individual against certain diseases, including his family members and community. After these attempts, if the refusal to vaccinate their children persists, physicians may try the following alternatives. (a) Accept the rejection and merely conclude the consultation with the phrase "it is your choice;" (b) adopt other measures of social pressure such as the requirement of vaccination by schools and kindergartens, and (c) abandon the patient and refuse to attend that family. Which of these measures would be the most ethically appropriate? The first one, in which the professional considers himself defeated and leaves the decision to the parents knowing they will not vaccinate their children? The second form of referral, even though does not depend on the professional since he must follow the institutions' requirements and legal norms? And the third option, no longer to attend the family? The latter is going to be treated in a specific topic. It is possible to notice that numerous measures adopted in several countries use different strategies to overcome the declared war against the undecided people.

would do so if there is a refusal for all vaccines [72]. This practice more than doubled between 2006 and 2013 among the US pediatricians [73], despite recommendations to the contrary from the CDC and AAP. The following arguments are presented to justify that medical attitude. (a) It could configure a professional unethical act; (b) represents an insurmountable difference of values between parents and professionals; (c) families with unvaccinated children constitute a danger to the clinic staff and other patients; (d) their counseling requires a lot of time from the physician and (e) they do not want to be responsible for vaccine-preventable infectious diseases of their little patients [74]. Under such circumstances, how should the physicians get prepared to fight epidemics and how to act on their obligations, responsibilities, rights, and values? [75]. Thus, is the physicians' reaction ethically justifiable? When analyzed in detail, it is worth noting that a renunciation behavior is not consistent with physicians' ethical obligations and none of these reasons are sufficient to support such a decision [72]. The AMA does not recommend this procedure because it is unethical to abandon the patients. The physician has the ethical commitment of beneficence and non-maleficence and this decision does not meet the best interest of the child (charity) since persisting the non-vaccination can make the physician responsible for possible harm (not maleficence) [73]. Remember that the most reli-

The Ethical Duty of Physicians to Strengthen Their Own Immunization and Childhood Vaccination

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17

able source of vaccine information for parents is the doctor himself [76, 77].

conditions and continues with medical care [67].

**6. Final considerations**

It is also difficult to consider the physicians' attitude as a conscience objection of parents' immoral act because against that decision arises the principles of public health in which children could be a source of infection for others, in case they acquire a disease preventable by the vaccine [78]. Therefore, it is necessary to strengthen the relationship with parents, especially the families with low educational or socioeconomic levels [79]. As a guideline for the clinician in these pediatric care situations, an alternative could only occur in the following cases. (a) To exhaust all means of education with the family; (b) the family is informed of the physician's decision; (c) the geographic region is not in need of pediatric doctors and (d) he must continue to promote health care until the family finds another physician who agrees to provide care (usually 30 days) [78]. In extreme cases, some families will refuse vaccination regardless the method of communication used. In that case, the physician's reluctance may be an option accepted by the American Academy of Pediatrics since another physician agrees with the

*Sin ética no hay futuro posible, ni a nivel local ni a nivel global* (Martinet de la Cerdanya)

Currently, it is acceptable to say that without ethics there will be no possible future in the world, and then, everyone must be aware of his duties and responsibilities to himself and the humanity's future. Therefore, it is essential that everyone helps each other since we live in a community, and it is also necessary to have a profound reflection regarding our behavior, attitudes, and acts that may help or cause harm to others. Such scenario of concern for public health fits very well with the physicians' vaccination issue and children of our planet in understanding their social role of protecting as many people as possible against the reemergence of old infections. Thus, it is the physicians' ethical and moral responsibility to act favorably in

One of them, considered by some as a stimulating measure for vaccination, is the implementation of compensation programs for damages by vaccines. Such a program has been increasingly used as a component of vaccination programs for more than 50 years. Recently, a restrictive measure was adopted by the American Academy of Pediatrics recommending health institutions to eliminate non-medical exemptions in refusing vaccination because in the past 20 years the number of non-medical exemptions for school students, in the United States, has nearly doubled for philosophical or religious reasons, especially the first one. Then, coercive actions can be taken by the state, which has the responsibility to protect its citizens.

Thus, the adoption of restrictive measures of freedom such as isolation and quarantine can be ethical justifications [69]. Also, the European Convention on Human Rights, among the exceptions provided, allows the legal detention of persons to prevent the spread of infectious diseases. Several European countries have adopted punitive measures penalizing those who refuse to vaccinate their children. Italy is the most recent example. The country's Supreme Court of Justice has made compulsory the use of vaccines for children and adolescents, allowing the executive power to impose fines on these parents and prevent their children from attending public schools. Recently, 27 French medical entities have launched a public manifesto supporting compulsory vaccination of children with the condition that the phase is transient until population confidence and health professionals are restored, and then, it should be voluntary again [70]. These measures have been implemented with the focus on parental responsibility and anchored in the principle of justice because it is intended that they authorize their children's vaccination with the perspective of community protection [71]. Finally, confidence-building strategies in health institutions are vital to increasing public acceptance as well as disseminating information on vaccine safety and efficacy.

#### **5.1. The refusal of physicians to attend parents who refuse to vaccinate their children**

#### *Hell isn't merely paved with good intentions, it is walled and roofed with them* (Aldous Huxley)

As a result of persistent refusals by parents to vaccinate their children, even after physicians' recommendations, a new challenge arises among professionals, especially for pediatricians, such as to avoid attending children in these situations. The subject is worrying. In the United States, 25% of pediatricians would refrain, at some point, from attending families under these conditions, while in Europe 9% of pediatricians supported such a decision and 27% of them would do so if there is a refusal for all vaccines [72]. This practice more than doubled between 2006 and 2013 among the US pediatricians [73], despite recommendations to the contrary from the CDC and AAP. The following arguments are presented to justify that medical attitude. (a) It could configure a professional unethical act; (b) represents an insurmountable difference of values between parents and professionals; (c) families with unvaccinated children constitute a danger to the clinic staff and other patients; (d) their counseling requires a lot of time from the physician and (e) they do not want to be responsible for vaccine-preventable infectious diseases of their little patients [74]. Under such circumstances, how should the physicians get prepared to fight epidemics and how to act on their obligations, responsibilities, rights, and values? [75]. Thus, is the physicians' reaction ethically justifiable? When analyzed in detail, it is worth noting that a renunciation behavior is not consistent with physicians' ethical obligations and none of these reasons are sufficient to support such a decision [72]. The AMA does not recommend this procedure because it is unethical to abandon the patients. The physician has the ethical commitment of beneficence and non-maleficence and this decision does not meet the best interest of the child (charity) since persisting the non-vaccination can make the physician responsible for possible harm (not maleficence) [73]. Remember that the most reliable source of vaccine information for parents is the doctor himself [76, 77].

It is also difficult to consider the physicians' attitude as a conscience objection of parents' immoral act because against that decision arises the principles of public health in which children could be a source of infection for others, in case they acquire a disease preventable by the vaccine [78]. Therefore, it is necessary to strengthen the relationship with parents, especially the families with low educational or socioeconomic levels [79]. As a guideline for the clinician in these pediatric care situations, an alternative could only occur in the following cases. (a) To exhaust all means of education with the family; (b) the family is informed of the physician's decision; (c) the geographic region is not in need of pediatric doctors and (d) he must continue to promote health care until the family finds another physician who agrees to provide care (usually 30 days) [78]. In extreme cases, some families will refuse vaccination regardless the method of communication used. In that case, the physician's reluctance may be an option accepted by the American Academy of Pediatrics since another physician agrees with the conditions and continues with medical care [67].

## **6. Final considerations**

following alternatives. (a) Accept the rejection and merely conclude the consultation with the phrase "it is your choice;" (b) adopt other measures of social pressure such as the requirement of vaccination by schools and kindergartens, and (c) abandon the patient and refuse to attend that family. Which of these measures would be the most ethically appropriate? The first one, in which the professional considers himself defeated and leaves the decision to the parents knowing they will not vaccinate their children? The second form of referral, even though does not depend on the professional since he must follow the institutions' requirements and legal norms? And the third option, no longer to attend the family? The latter is going to be treated in a specific topic. It is possible to notice that numerous measures adopted in several countries

use different strategies to overcome the declared war against the undecided people.

as well as disseminating information on vaccine safety and efficacy.

**children**

16 Reflections on Bioethics

**5.1. The refusal of physicians to attend parents who refuse to vaccinate their** 

*Hell isn't merely paved with good intentions, it is walled and roofed with them* (Aldous Huxley)

As a result of persistent refusals by parents to vaccinate their children, even after physicians' recommendations, a new challenge arises among professionals, especially for pediatricians, such as to avoid attending children in these situations. The subject is worrying. In the United States, 25% of pediatricians would refrain, at some point, from attending families under these conditions, while in Europe 9% of pediatricians supported such a decision and 27% of them

One of them, considered by some as a stimulating measure for vaccination, is the implementation of compensation programs for damages by vaccines. Such a program has been increasingly used as a component of vaccination programs for more than 50 years. Recently, a restrictive measure was adopted by the American Academy of Pediatrics recommending health institutions to eliminate non-medical exemptions in refusing vaccination because in the past 20 years the number of non-medical exemptions for school students, in the United States, has nearly doubled for philosophical or religious reasons, especially the first one. Then, coercive actions can be taken by the state, which has the responsibility to protect its citizens. Thus, the adoption of restrictive measures of freedom such as isolation and quarantine can be ethical justifications [69]. Also, the European Convention on Human Rights, among the exceptions provided, allows the legal detention of persons to prevent the spread of infectious diseases. Several European countries have adopted punitive measures penalizing those who refuse to vaccinate their children. Italy is the most recent example. The country's Supreme Court of Justice has made compulsory the use of vaccines for children and adolescents, allowing the executive power to impose fines on these parents and prevent their children from attending public schools. Recently, 27 French medical entities have launched a public manifesto supporting compulsory vaccination of children with the condition that the phase is transient until population confidence and health professionals are restored, and then, it should be voluntary again [70]. These measures have been implemented with the focus on parental responsibility and anchored in the principle of justice because it is intended that they authorize their children's vaccination with the perspective of community protection [71]. Finally, confidence-building strategies in health institutions are vital to increasing public acceptance

#### *Sin ética no hay futuro posible, ni a nivel local ni a nivel global* (Martinet de la Cerdanya)

Currently, it is acceptable to say that without ethics there will be no possible future in the world, and then, everyone must be aware of his duties and responsibilities to himself and the humanity's future. Therefore, it is essential that everyone helps each other since we live in a community, and it is also necessary to have a profound reflection regarding our behavior, attitudes, and acts that may help or cause harm to others. Such scenario of concern for public health fits very well with the physicians' vaccination issue and children of our planet in understanding their social role of protecting as many people as possible against the reemergence of old infections. Thus, it is the physicians' ethical and moral responsibility to act favorably in gaining parental trust, and then, the best way to do that is to give their example by being vaccinated and explain that to the patients because they influence parents' decisions to authorize children' vaccinations. Moreover, the professionals need to have sufficient knowledge about proposed vaccination regimens, efficacy and possible adverse events that are essential for an adequate and honest orientation to their patients.

[8] Offit PA. Deadly Choices. How the Anti-vaccine Movement Threatens Us All. New York:

The Ethical Duty of Physicians to Strengthen Their Own Immunization and Childhood Vaccination

http://dx.doi.org/10.5772/intechopen.75716

19

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Then, abandoning the families whose parents resist authorizing the vaccination of their children is not an ethical conduct. It is worth emphasizing that one way of increasing the physicians' importance is to unleash their altruistic spirit, and then, as a fundamental bioethical reference, they can contribute in a striking way to the objectives' achievement. Therefore, the binomial of physicians' vaccination and childhood vaccines promotion are ethical duties and sisterly attitudes, and they are indispensable to make the ethical side of this war win in the name of human welfare and with decisive physicians' participation.

## **Author details**

Bruno Rodolfo Schlemper Junior1 \*, Vilma Beltrame1 and Fernando Hellmann2

\*Address all correspondence to: schlemper.junior@gmail.com

1 Graduate degree in Biosciences and Health of West Santa Catarina University, Joaçaba, Brazil

2 Public Health Department, Federal University of Santa Catarina, Florianópolis, Brazil

## **References**


[8] Offit PA. Deadly Choices. How the Anti-vaccine Movement Threatens Us All. New York: Basic Books; 2015. (prologue). 272 p. ISBN: 978-0-465-02149-9

gaining parental trust, and then, the best way to do that is to give their example by being vaccinated and explain that to the patients because they influence parents' decisions to authorize children' vaccinations. Moreover, the professionals need to have sufficient knowledge about proposed vaccination regimens, efficacy and possible adverse events that are essential for an

Then, abandoning the families whose parents resist authorizing the vaccination of their children is not an ethical conduct. It is worth emphasizing that one way of increasing the physicians' importance is to unleash their altruistic spirit, and then, as a fundamental bioethical reference, they can contribute in a striking way to the objectives' achievement. Therefore, the binomial of physicians' vaccination and childhood vaccines promotion are ethical duties and sisterly attitudes, and they are indispensable to make the ethical side of this war win in the

\*, Vilma Beltrame1

2 Public Health Department, Federal University of Santa Catarina, Florianópolis, Brazil

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and Fernando Hellmann2

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**Author details**

18 Reflections on Bioethics

Joaçaba, Brazil

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Bruno Rodolfo Schlemper Junior1

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\*Address all correspondence to: schlemper.junior@gmail.com

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pdf [Access: 2018-01-31]


**Chapter 2**

Provisional chapter

**Bioethics in Critical Care Patients**

Bioethics in Critical Care Patients

Additional information is available at the end of the chapter

Intensive care unit is a special medial environment for many reasons (the severity of the patients, the important technological advances). In recent years, the medicine has changed to a more focused practice on the patient, leaving behind the paternalistic medical approach, with a transparent new relationship with the patient and his family. The ethical principles-autonomy, beneficence, non-maleficence and justice-and the possibility of conflicts between them make decision-making very complex. The admission of these patients in our unit is justified based on a triangle-acute, severe, and recoverable disease-trying to optimize their treatment. Unfavorable later evolution is possible; a palliative management can often be considered, changing the patient's approach from the cure of his illness to the relief of his symptoms. Decisions about patient's future must be jointly made by the health care team, the patient and his family. We must look for documents about previous instructions and/or opinion of a substitute decision-maker. We must humanize our units, thinking about the best care for the sick person and his family, and improve the support to the family after his death. Therefore, the development of practice guidelines on palliative care

DOI: 10.5772/intechopen.75565

Keywords: bioethics, intensive care unit, patient's best interests, withdrawal treatment,

The important advances made over the last decades in the field of critical care have led to an increase in survival and an increase in prevalence of chronic diseases. This in turn has focused

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

Additional information is available at the end of the chapter

Miguel Ángel García García,

Miguel Ángel García García,

Alfonso Martínez Cornejo

Alfonso Martínez Cornejo

Abstract

María Ángeles Rosero Arenas and

María Ángeles Rosero Arenas and

http://dx.doi.org/10.5772/intechopen.75565

should be promoted by the hospitals.

withholding treatment

growing attention on end-of-life care.

1. Introduction

#### **Chapter 2** Provisional chapter

#### **Bioethics in Critical Care Patients** Bioethics in Critical Care Patients

Miguel Ángel García García, María Ángeles Rosero Arenas and Alfonso Martínez Cornejo Miguel Ángel García García, María Ángeles Rosero Arenas and Alfonso Martínez Cornejo

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.75565

#### Abstract

Intensive care unit is a special medial environment for many reasons (the severity of the patients, the important technological advances). In recent years, the medicine has changed to a more focused practice on the patient, leaving behind the paternalistic medical approach, with a transparent new relationship with the patient and his family. The ethical principles-autonomy, beneficence, non-maleficence and justice-and the possibility of conflicts between them make decision-making very complex. The admission of these patients in our unit is justified based on a triangle-acute, severe, and recoverable disease-trying to optimize their treatment. Unfavorable later evolution is possible; a palliative management can often be considered, changing the patient's approach from the cure of his illness to the relief of his symptoms. Decisions about patient's future must be jointly made by the health care team, the patient and his family. We must look for documents about previous instructions and/or opinion of a substitute decision-maker. We must humanize our units, thinking about the best care for the sick person and his family, and improve the support to the family after his death. Therefore, the development of practice guidelines on palliative care should be promoted by the hospitals.

DOI: 10.5772/intechopen.75565

Keywords: bioethics, intensive care unit, patient's best interests, withdrawal treatment, withholding treatment

#### 1. Introduction

The important advances made over the last decades in the field of critical care have led to an increase in survival and an increase in prevalence of chronic diseases. This in turn has focused growing attention on end-of-life care.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

A significant number of patients (a value close to 10%) die in the intensive care units (ICU) [1]; in many of them, the so-called limitation of life support therapy (LLST) is carried out either because it is not possible to offer a curative treatment or because the patient expressly refuses to undergo further tests or treatment.

The intensivist must always pursue the best interest for the patient, and this does not necessarily mean saving his life, in cases where, for example, the prognosis is bad and the "cost to

Bioethics in Critical Care Patients

29

http://dx.doi.org/10.5772/intechopen.75565

Health professionals, patients, and their families share responsibility for the distribution of community resources for health problems. These resources are limited and should be used judiciously. The medical staff and the patient, and their family, should keep in mind that responsibility also concerns them. The management of the services provided by the health system must be careful, it must include respect for the individual decisions of the patient, and resources must be maximized. Resources should not be so scarce as to justify preventable

It constitutes the sum of the principles of beneficence, non-maleficence, and autonomy; i.e., the patient's best interest is pursued if the doctor acts to benefit the patient, avoids the damage, and takes into consideration, together with the apparent prognosis of the patients and his favorable or not favorable response to the treatment, his wishes, values, and objectives, depending on the clinical circumstances of the case. This is paramount because the patients´ perception of what is best for them sometimes differs from the doctor's opinion. Every patient whose decision-making capacity is intact has the right to accept or refuse the treatment proposed by the medical team. Sometimes the best interest of the patient will be achieved with

The role of the intensivist doctor is also relevant in end-of-life situations, because they are well acquainted with the natural history of critical pathology, such as the treatment options avail-

The sources of information that the intensivist doctor reviews for this transcendent decisionmaking are the medical history, anticipated decision-making, or the point of view of the parents, relatives, or legal guardian. In emergency situations, in which the wishes of the patient are unknown and there is no other source of information available, the available

Bioethical principles have two levels: first level, public or collective (Justice and Non-Maleficence) and second level, private or individual (Beneficence and Autonomy). If there is a conflict between these principles, first level principles have priority; that is, the second level principles are mandatory if they do not conflict with those of the first level [7]. There may be conflict between bioethical principles from the point of view of patients between what they expect as a population (Distributive Justice) and what they expect at the personal level (Benef-

pay" is extremely high in time, resources and suffering of the patient [6].

deaths. The population should be aware that ICU beds are limited.

the withdrawal or not starting (withholding) treatment.

able in the ICU, as well as the risks and complications.

2.5. Conflicts between bioethical principles

icence and Autonomy).

support maneuvers must be initiated until the situation is clarified.

2.3. Principle of justice (distributive)

2.4. Principle of patient's best interests

Spanish studies indicate that the limitation of life support is made between 10 and 12% of the patients admitted to the ICU [2, 3]. The current vision of intensive medicine is more focused on the patient's well-being and autonomy, in contrast to the older, more paternalistic one, that is, focused on the doctor and his decisions [4].

## 2. Ethical principles and decision-making

According to the principles of good medical practice that emanate from the recommendations of the Collegiate Medical Organization [5], the doctor must act in the best interest of the patient. The ethical framework for decision-making includes four basic principles, and religious and cultural issues are intimately related to their interpretation.

#### 2.1. Principle of autonomy

Autonomy is the right that people have to make their own decisions regarding their health and illness in the absence of coercion and with the necessary information. It means knowing all the available treatments options and the possible consequences of their use of the fact of inhibiting their use. Underlying this principle is the importance of informed consent (IC) for any procedure.

This principle does not oblige the doctor to administer a treatment against his opinion due to the fact that the patient requests it. The intensivist on the other hand must administer the treatment that offers the greatest benefit to the patient, the least harmful, providing all the necessary information and obtaining the IC.

If there are doubts about the patient's ability to refuse treatment and there are no anticipated decisions, life support should be offered until the issue is clarified.

Consent for a treatment may not be sought in an emergency situation, if this treatment is necessary to save the life of the patient or if it prevents or can prevent serious harm.

#### 2.2. Principles of beneficence and non-maleficence

It refers respectively to benefit the patient in the first place and to avoid physical, psychological, or moral damage in the second. All these followed the old Latin aphorism "primum non nocere". The risks and the potential benefit or each intervention should also be weighted in intensive therapy. In case of doubt, the intervention of the family could clarify what are the best interests of the patient. If still, there is no agreement, the participation of the Bioethics committee may be useful to define the case.

The intensivist must always pursue the best interest for the patient, and this does not necessarily mean saving his life, in cases where, for example, the prognosis is bad and the "cost to pay" is extremely high in time, resources and suffering of the patient [6].

## 2.3. Principle of justice (distributive)

A significant number of patients (a value close to 10%) die in the intensive care units (ICU) [1]; in many of them, the so-called limitation of life support therapy (LLST) is carried out either because it is not possible to offer a curative treatment or because the patient expressly refuses

Spanish studies indicate that the limitation of life support is made between 10 and 12% of the patients admitted to the ICU [2, 3]. The current vision of intensive medicine is more focused on the patient's well-being and autonomy, in contrast to the older, more paternalistic one, that is,

According to the principles of good medical practice that emanate from the recommendations of the Collegiate Medical Organization [5], the doctor must act in the best interest of the patient. The ethical framework for decision-making includes four basic principles, and reli-

Autonomy is the right that people have to make their own decisions regarding their health and illness in the absence of coercion and with the necessary information. It means knowing all the available treatments options and the possible consequences of their use of the fact of inhibiting their use. Underlying this principle is the importance of informed consent (IC) for

This principle does not oblige the doctor to administer a treatment against his opinion due to the fact that the patient requests it. The intensivist on the other hand must administer the treatment that offers the greatest benefit to the patient, the least harmful, providing all the

If there are doubts about the patient's ability to refuse treatment and there are no anticipated

Consent for a treatment may not be sought in an emergency situation, if this treatment is

It refers respectively to benefit the patient in the first place and to avoid physical, psychological, or moral damage in the second. All these followed the old Latin aphorism "primum non nocere". The risks and the potential benefit or each intervention should also be weighted in intensive therapy. In case of doubt, the intervention of the family could clarify what are the best interests of the patient. If still, there is no agreement, the participation of the Bioethics

necessary to save the life of the patient or if it prevents or can prevent serious harm.

to undergo further tests or treatment.

28 Reflections on Bioethics

2.1. Principle of autonomy

any procedure.

focused on the doctor and his decisions [4].

necessary information and obtaining the IC.

2.2. Principles of beneficence and non-maleficence

committee may be useful to define the case.

2. Ethical principles and decision-making

gious and cultural issues are intimately related to their interpretation.

decisions, life support should be offered until the issue is clarified.

Health professionals, patients, and their families share responsibility for the distribution of community resources for health problems. These resources are limited and should be used judiciously. The medical staff and the patient, and their family, should keep in mind that responsibility also concerns them. The management of the services provided by the health system must be careful, it must include respect for the individual decisions of the patient, and resources must be maximized. Resources should not be so scarce as to justify preventable deaths. The population should be aware that ICU beds are limited.

#### 2.4. Principle of patient's best interests

It constitutes the sum of the principles of beneficence, non-maleficence, and autonomy; i.e., the patient's best interest is pursued if the doctor acts to benefit the patient, avoids the damage, and takes into consideration, together with the apparent prognosis of the patients and his favorable or not favorable response to the treatment, his wishes, values, and objectives, depending on the clinical circumstances of the case. This is paramount because the patients´ perception of what is best for them sometimes differs from the doctor's opinion. Every patient whose decision-making capacity is intact has the right to accept or refuse the treatment proposed by the medical team. Sometimes the best interest of the patient will be achieved with the withdrawal or not starting (withholding) treatment.

The role of the intensivist doctor is also relevant in end-of-life situations, because they are well acquainted with the natural history of critical pathology, such as the treatment options available in the ICU, as well as the risks and complications.

The sources of information that the intensivist doctor reviews for this transcendent decisionmaking are the medical history, anticipated decision-making, or the point of view of the parents, relatives, or legal guardian. In emergency situations, in which the wishes of the patient are unknown and there is no other source of information available, the available support maneuvers must be initiated until the situation is clarified.

#### 2.5. Conflicts between bioethical principles

Bioethical principles have two levels: first level, public or collective (Justice and Non-Maleficence) and second level, private or individual (Beneficence and Autonomy). If there is a conflict between these principles, first level principles have priority; that is, the second level principles are mandatory if they do not conflict with those of the first level [7]. There may be conflict between bioethical principles from the point of view of patients between what they expect as a population (Distributive Justice) and what they expect at the personal level (Beneficence and Autonomy).

The intensivist also experiences conflict between his duties toward different patients outside and inside the ICU. The limitation of resources (available beds) may mean that the treatment that is desired to be administered or that is believed to be beneficial for the patient cannot be administered. Health resources must be localized so that they provide the greatest benefit to a greater number of patients. If the ICU is full, it may be necessary to transfer the patient to another hospital. When the intensivist must choose between patients, the priority should be those patients with the highest probability of benefit for admission to the ICU. The intensivists must perform reasonable actions (with the capacity to justify them) and with responsibility (clear knowledge of their obligations and knowing that the consequences of the decisions fall on them).

for a limited period with defined expectations for certain outcomes (consensus building), insisting on interrupting painful and unpleasant treatments because they do not cause benefits. It is useful to redefine the objective of treating the patient in a positive way, insisting on treatments that can help him/her more than those that do not help him. The best way to establish the patient's best interest is the doctor's conversation with the patient (when he/she

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This point is crucial because it constitutes the cornerstone in determining the best interest of the patient, especially if he has no ability to express himself. In short, if the doctor thinks that a certain treatment will not bring significant benefits to the patient, the one that does not initiate or suspend is irrelevant. What is really happening is that the natural history of the disease is acting. There may be different points of view about what life means. Some people think that the value of life is infinite; others think that life has value only if it has quality. For those who have the first point of view, the agreement on withdrawing or not initiating a treatment may be difficult

The juridical international framework focuses on two reference elements in Bioethics: the Agreement on Human Rights and Biomedicine (Council of Europe 1997) [10] and the Universal Declaration on Bioethics of the UNESCO in 2005 [11]. Both standards recognize the right to decide, after appropriate information, by people, who can voluntarily decide for themselves which treatments or interventions they accept or reject. Legality has evolved to give priority to the principles of autonomy freedom, equality, and respect for sanctity—inviolability of human life. Adults able to decide can refuse treatment even if this is danger to their life. On the other hand, they have the right to effective communication to make the decisions they consider

The planning of early decisions, or advanced care directives (ACD), and a substitute decision-

The options of withholding and/or withdrawing supportive therapy are considered legal and appropriate in circumstances in which there is a valid recess of such treatment, either because the patient requests it or because the doctor considers that such treatment does not pursue the best interest of the patient. On the other hand, euthanasia, or assisted death, defined as those situations in which the doctor administers or removes substances in order to end the life of the patient or shorten it, is not legal under any circumstance in our current legal framework. An act is criminal according to the underlying intention. If a treatment is administered, a foreseeable shortening of the patient's life may occur, although that is not its purpose, and it is legal if its goal is not to shorten life (doctrine of "Double Effect"). That is, death is expected but not persecuted by that action. Intensivists should not use the term Euthanasia, and they should accurately describe the actions they carry out, such as removing ineffective and burdensome

can express him/herself) and his family [9].

3. Legal framework: End of life care

appropriate and to an informed choice.

treatment and initiating palliative treatment.

maker could also help to a patient that cannot make a decision.

to achieve.

#### 2.6. Cultural and religious issues

The relationship between the four bioethical principles can be modified by religious and cultural views of the patient and the doctor. The intensivist must respect the perspective and values of the family, and even sometimes he/she should look for someone with the capacity to interpret these topics that help to solve problems that fit in the perspective of the patient and his/her family. For example, it must be explained in a brain death situation that the brain has died, although the different point of view of the family should be accepted, and must explain that the heart will stop shortly afterward.

#### 2.7. Removal of the treatment (withdrawal) and non start (withholding)

From a philosophical and ethical standpoint, there is no difference between these two options. This means that, if all the circumstances to be assessed in the decision-making are equal and if it is ethical not to initiate a treatment to patients, it would be equally ethical to withdraw it if already begun. Not initiate or withdraw a treatment, which the intensivist thinks is not helping the patient, is not killing the patient, but the evolution of the disease is influencing the poor prognosis. In spite of everything, many doctors consider that not starting a treatment is different from withdrawing.

If the patient has expressed clearly (though not in writing) his desire not to continue or initiate a particular treatment, the intensivist is obliged to follow the evolutionary course of the patient as a continuation of that desire [8]. When the wishes of palliative care by the patient agree with good medical care, there are sure reasons to withdraw the treatment.

Some circumstances surrounding the decision of withdrawing or withholding may be different; i.e., the first option is more frequent with the ICU, while the second one is usually outside the ICU. Sometimes, the chosen option may be a trial of treatment of limited time, proposing from the beginning to withdraw it if ineffective in this period; this plan allows collecting additional information about the patient's situation. If the intensivist does not have a clear option to withdraw a treatment, he should ask a question: knowing what he knows about the patient, would he enter the patient in the ICU and start an invasive treatment? If the answer is negative, the treatment should be withdrawn.

If the family is reluctant to withdraw a treatment, it may be useful to negotiate an initial agreement on not escalating the treatment if there is no improvement or to continue treatment for a limited period with defined expectations for certain outcomes (consensus building), insisting on interrupting painful and unpleasant treatments because they do not cause benefits. It is useful to redefine the objective of treating the patient in a positive way, insisting on treatments that can help him/her more than those that do not help him. The best way to establish the patient's best interest is the doctor's conversation with the patient (when he/she can express him/herself) and his family [9].

This point is crucial because it constitutes the cornerstone in determining the best interest of the patient, especially if he has no ability to express himself. In short, if the doctor thinks that a certain treatment will not bring significant benefits to the patient, the one that does not initiate or suspend is irrelevant. What is really happening is that the natural history of the disease is acting.

There may be different points of view about what life means. Some people think that the value of life is infinite; others think that life has value only if it has quality. For those who have the first point of view, the agreement on withdrawing or not initiating a treatment may be difficult to achieve.

## 3. Legal framework: End of life care

The intensivist also experiences conflict between his duties toward different patients outside and inside the ICU. The limitation of resources (available beds) may mean that the treatment that is desired to be administered or that is believed to be beneficial for the patient cannot be administered. Health resources must be localized so that they provide the greatest benefit to a greater number of patients. If the ICU is full, it may be necessary to transfer the patient to another hospital. When the intensivist must choose between patients, the priority should be those patients with the highest probability of benefit for admission to the ICU. The intensivists must perform reasonable actions (with the capacity to justify them) and with responsibility (clear knowledge of their obligations and knowing that the consequences of the decisions fall on them).

The relationship between the four bioethical principles can be modified by religious and cultural views of the patient and the doctor. The intensivist must respect the perspective and values of the family, and even sometimes he/she should look for someone with the capacity to interpret these topics that help to solve problems that fit in the perspective of the patient and his/her family. For example, it must be explained in a brain death situation that the brain has died, although the different point of view of the family should be accepted, and must explain

From a philosophical and ethical standpoint, there is no difference between these two options. This means that, if all the circumstances to be assessed in the decision-making are equal and if it is ethical not to initiate a treatment to patients, it would be equally ethical to withdraw it if already begun. Not initiate or withdraw a treatment, which the intensivist thinks is not helping the patient, is not killing the patient, but the evolution of the disease is influencing the poor prognosis. In spite of everything, many doctors consider that not starting a treatment is

If the patient has expressed clearly (though not in writing) his desire not to continue or initiate a particular treatment, the intensivist is obliged to follow the evolutionary course of the patient as a continuation of that desire [8]. When the wishes of palliative care by the patient agree with

Some circumstances surrounding the decision of withdrawing or withholding may be different; i.e., the first option is more frequent with the ICU, while the second one is usually outside the ICU. Sometimes, the chosen option may be a trial of treatment of limited time, proposing from the beginning to withdraw it if ineffective in this period; this plan allows collecting additional information about the patient's situation. If the intensivist does not have a clear option to withdraw a treatment, he should ask a question: knowing what he knows about the patient, would he enter the patient in the ICU and start an invasive treatment? If the answer is

If the family is reluctant to withdraw a treatment, it may be useful to negotiate an initial agreement on not escalating the treatment if there is no improvement or to continue treatment

2.7. Removal of the treatment (withdrawal) and non start (withholding)

good medical care, there are sure reasons to withdraw the treatment.

2.6. Cultural and religious issues

30 Reflections on Bioethics

that the heart will stop shortly afterward.

negative, the treatment should be withdrawn.

different from withdrawing.

The juridical international framework focuses on two reference elements in Bioethics: the Agreement on Human Rights and Biomedicine (Council of Europe 1997) [10] and the Universal Declaration on Bioethics of the UNESCO in 2005 [11]. Both standards recognize the right to decide, after appropriate information, by people, who can voluntarily decide for themselves which treatments or interventions they accept or reject. Legality has evolved to give priority to the principles of autonomy freedom, equality, and respect for sanctity—inviolability of human life. Adults able to decide can refuse treatment even if this is danger to their life. On the other hand, they have the right to effective communication to make the decisions they consider appropriate and to an informed choice.

The planning of early decisions, or advanced care directives (ACD), and a substitute decisionmaker could also help to a patient that cannot make a decision.

The options of withholding and/or withdrawing supportive therapy are considered legal and appropriate in circumstances in which there is a valid recess of such treatment, either because the patient requests it or because the doctor considers that such treatment does not pursue the best interest of the patient. On the other hand, euthanasia, or assisted death, defined as those situations in which the doctor administers or removes substances in order to end the life of the patient or shorten it, is not legal under any circumstance in our current legal framework. An act is criminal according to the underlying intention. If a treatment is administered, a foreseeable shortening of the patient's life may occur, although that is not its purpose, and it is legal if its goal is not to shorten life (doctrine of "Double Effect"). That is, death is expected but not persecuted by that action. Intensivists should not use the term Euthanasia, and they should accurately describe the actions they carry out, such as removing ineffective and burdensome treatment and initiating palliative treatment.

It is essential for intensivists to familiarize themselves with the legislation in force in each territory in which they practice medicine. In some places, it is mandatory to have consensus with the patients or with the substitute decision-maker, to withdraw or not initiate a treatment, when it is thought that these do not pursue the best interest of the patient. The doctor who ignores a patient's desire to suspend a certain treatment (even if thus puts his life at risk) risks criminal prosecution.

patients who end up dying and the quality of the human relationships involved in each death [13]. In general, admission to the ICU should be reserved for patients with reversible diseases whose prognosis can be improved with the human material and available technology. There may be other reasons: a treatment attempt limited in time when the degree of irreversibility is unknown, difficult management of symptoms (including palliative care), and consideration of

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At any time during admission, the goal of treatment can be changed from curative to palliative (Figure 1). The assessment of the suitability of the admission is based on the fact that the probable prognosis is acceptable for the patient, and that the burdens/risks of the treatment exceed its benefit. In patients with advanced age, frail, and with significant comorbidity, it is difficult to identify the possible benefits of their admission to the UCI. The prognosis scores are of limited value when applied to individual cases, especially in older people with comorbidities. The so-called "surprise questions" are useful when it comes to clarifying the picture: questions such as "Would you be surprised if the patient died in the following 6-12 months?" as well as others of functional character (more than 50% of time in bed, frequent hospital admissions, little autonomy in basic activities, loss of more than 10%

The decisions not to admit a patient to the ICU, as well as a limited time of treatment in the ICU, are ways of LLST. A deliberative process should be carried out by the treating team of the patient, with a collegial decision that allows offering other options than nonadmission, as admission with agreed treatment measures, assessing a response time, etc. This decision should be shared with other members of the team, as well as with the family and the patient.

The admission of patients with terminal or intractable diseases would not be considered, although exceptionally the admission of patients requiring palliative care to better manage

The determination of the patient's prognosis before and during admission is extremely difficult. It involves integrating several data: current clinical assessment, information from other medical teams, impact of ICU treatments on life expectancy, and the chronic diseases of the

All these processes must be recorded in the clinical history.

Figure 1. Continuity of the care of the patients at the end of life.

end-of-life care could be considered.

5. Palliative care in ICU

patient.

organ donation.

of weight in the last 5 months).

By the other side, it is not true that the patient has the right to demand a certain treatment that he considers appropriate if the doctor does not agree with him.

When there is no agreement between intensivist and relatives, the case may be referred to the court or to the Supreme Court. The decisions made in accordance with the patient, especially if they are directed to their own benefit, must be well documented and sometimes even commented with a psychiatrist. If there are early decisions, in the sense of refusing a treatment, they must be followed. If the patient has appointed a substitute decision-maker, what he says must be respected.

Children and young people who have not reached a minimum age to make decisions; the best interest of the children is supreme, and usually intensivists rely on their parents to make the best decision in their favor. Sometimes, adolescents and older children are considered "mature" to make decisions, without the need for parental permission. If the child has his own point of view, he should be given the opportunity to express himself, and it will be given importance in relation to the development of the child's capacity and circumstances. For example, Jehovah's Witnesses who refuse to be transfused in situations of life-threatening anemia, despite the apparent maturity and intelligence of the adolescent, may be considered to have no ability to reject potentially life-saving measures; in these circumstances, the principle of the child's best interest may prevail over the principle of Autonomy.

The shared decision is the best model to follow in situations at the end of life and there is no room for unilateral decisions. The intensivist must be very careful about projecting their own point of view when it comes to assessing the quality of life of each patient, particularly when it comes to degenerative and chronic diseases, avoiding pejorative terms such as futility, very expensive, not beneficial, etc. Occasionally, medical interventions that cause suffering may be acceptable to the patient if a benefit in terms of prognosis or health status, or other objective value, can be achieved. If the treatment causes suffering, it should be avoided if it clearly does not bring any benefit [12]. The best interest of the patient assumes that the treatment should not be continued only to prolong life in any way.

It is very probable that a thoughtful, meditated, and consensual decision finds support in the legal framework. The laws recognize that in some circumstances, the mere prolongation of life does not follow the best interests of the patient. The withdrawal of life support treatment can shorten life, but not extending it to delay an inevitable end can follow the best interests of the patient.

## 4. Criteria for admission to the ICU

The success of intensive care should be measured by the quality of life preserved and not only by survival statistics. It should also be taken into account the quality of the process of death of patients who end up dying and the quality of the human relationships involved in each death [13]. In general, admission to the ICU should be reserved for patients with reversible diseases whose prognosis can be improved with the human material and available technology. There may be other reasons: a treatment attempt limited in time when the degree of irreversibility is unknown, difficult management of symptoms (including palliative care), and consideration of organ donation.

At any time during admission, the goal of treatment can be changed from curative to palliative (Figure 1). The assessment of the suitability of the admission is based on the fact that the probable prognosis is acceptable for the patient, and that the burdens/risks of the treatment exceed its benefit. In patients with advanced age, frail, and with significant comorbidity, it is difficult to identify the possible benefits of their admission to the UCI. The prognosis scores are of limited value when applied to individual cases, especially in older people with comorbidities. The so-called "surprise questions" are useful when it comes to clarifying the picture: questions such as "Would you be surprised if the patient died in the following 6-12 months?" as well as others of functional character (more than 50% of time in bed, frequent hospital admissions, little autonomy in basic activities, loss of more than 10% of weight in the last 5 months).

Figure 1. Continuity of the care of the patients at the end of life.

The decisions not to admit a patient to the ICU, as well as a limited time of treatment in the ICU, are ways of LLST. A deliberative process should be carried out by the treating team of the patient, with a collegial decision that allows offering other options than nonadmission, as admission with agreed treatment measures, assessing a response time, etc. This decision should be shared with other members of the team, as well as with the family and the patient. All these processes must be recorded in the clinical history.

The admission of patients with terminal or intractable diseases would not be considered, although exceptionally the admission of patients requiring palliative care to better manage end-of-life care could be considered.

## 5. Palliative care in ICU

It is essential for intensivists to familiarize themselves with the legislation in force in each territory in which they practice medicine. In some places, it is mandatory to have consensus with the patients or with the substitute decision-maker, to withdraw or not initiate a treatment, when it is thought that these do not pursue the best interest of the patient. The doctor who ignores a patient's desire to suspend a certain treatment (even if thus puts his life at risk) risks criminal prosecution. By the other side, it is not true that the patient has the right to demand a certain treatment that

When there is no agreement between intensivist and relatives, the case may be referred to the court or to the Supreme Court. The decisions made in accordance with the patient, especially if they are directed to their own benefit, must be well documented and sometimes even commented with a psychiatrist. If there are early decisions, in the sense of refusing a treatment, they must be followed. If the patient has appointed a substitute decision-maker, what he says

Children and young people who have not reached a minimum age to make decisions; the best interest of the children is supreme, and usually intensivists rely on their parents to make the best decision in their favor. Sometimes, adolescents and older children are considered "mature" to make decisions, without the need for parental permission. If the child has his own point of view, he should be given the opportunity to express himself, and it will be given importance in relation to the development of the child's capacity and circumstances. For example, Jehovah's Witnesses who refuse to be transfused in situations of life-threatening anemia, despite the apparent maturity and intelligence of the adolescent, may be considered to have no ability to reject potentially life-saving measures; in these circumstances, the princi-

The shared decision is the best model to follow in situations at the end of life and there is no room for unilateral decisions. The intensivist must be very careful about projecting their own point of view when it comes to assessing the quality of life of each patient, particularly when it comes to degenerative and chronic diseases, avoiding pejorative terms such as futility, very expensive, not beneficial, etc. Occasionally, medical interventions that cause suffering may be acceptable to the patient if a benefit in terms of prognosis or health status, or other objective value, can be achieved. If the treatment causes suffering, it should be avoided if it clearly does not bring any benefit [12]. The best interest of the patient assumes that the treatment should

It is very probable that a thoughtful, meditated, and consensual decision finds support in the legal framework. The laws recognize that in some circumstances, the mere prolongation of life does not follow the best interests of the patient. The withdrawal of life support treatment can shorten life,

The success of intensive care should be measured by the quality of life preserved and not only by survival statistics. It should also be taken into account the quality of the process of death of

but not extending it to delay an inevitable end can follow the best interests of the patient.

ple of the child's best interest may prevail over the principle of Autonomy.

not be continued only to prolong life in any way.

4. Criteria for admission to the ICU

he considers appropriate if the doctor does not agree with him.

must be respected.

32 Reflections on Bioethics

The determination of the patient's prognosis before and during admission is extremely difficult. It involves integrating several data: current clinical assessment, information from other medical teams, impact of ICU treatments on life expectancy, and the chronic diseases of the patient.

As we have seen before, age should not be an exclusive factor when deciding to enter the ICU. Comorbidities, degree of dependency, chronic diseases in advanced stage, and dementia frequently occur with increasing age should be valued as a whole. Talking and mobility are also factors to be assessed. Baseline quality indicators of the patient, together with specific disease markers, may indicate that the patient has started an inexorable path toward death.

The quality of life at the end of life can be defined in several ways. Smith [16] gives us a

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It is difficult to evaluate the quality of end-of-life care. The main judge on this process, the patient, dies in a high percentage of occasions. The delivery of a long questionnaire to the family can be understood as intrusive by them. Attention may be paid to other indicators that things have been done well: expressions of gratitude from the family at the time of death, other indirect expressions of gratitude (such as financial donations to the hospital), absence of

definition that is based on 12 principles (Table 1):

complaints about external interference, etc.

• be able to maintain control of what happens;

• control and choose where death occurs;

Table 1. Definition of quality of end of life.

• ensure dignity and privacy;

• know that death is coming, and understand what can be expected;

• have access to information and experience about what is necessary;

• have control over pain relief and control other symptoms;

• have access to any spiritual and emotional support required; • control who is present and with whom we share the end;

• have time to say good-bye, and control other aspects of time; • be able to leave when it is time, and not prolong life indefinitely.

• have access to proximity care, not just hospital care;

6. Consensus building, communication: Documentation

• be able to direct the advance care directives that ensure that the wishes are respected;

with the patient, his family, or his decision-making substitute.

must be constructive.

Consensus is an opinion or decision reached by a group as a whole, and it can be followed by all group members even if it is not the preferred option of each individual. This decision of shared decision makes the decision less subject to complaints or legal review than decisions reached by other methods (paternalistic exclusively by the doctor, majority vote, identification of a family member with the right to make any important decision in the patient). This consensus should ideally be achieved between the different medical teams before meeting

The relations between intensivists and other specialists, in order to build a common option,

The discussion must take place at different stages over time, and the meetings must be planned. They must include ICU nurses, social workers, chaplains, and patient families. Communication skills and the proper use of language are very important. Words such as "do everything," "do nothing," "futility," "uselessness" should be avoided, and the "value of treatment options" should be avoided, rather than "the value of the person." The documentation of the decision-

It is important to assess other failures such as terminal heart failure, respiratory failure with home oxygen, renal failure in hemodialysis, or advanced cancer.

When it has been decided to move from the goal of intensive to palliative care, efforts must be made to achieve its main objectives. The WHO definition of palliative treatment is [14]: "treatment approach that improves the quality of life of the patient and their families, and maintains the comfort and dignity of the patient, with prevention and alleviation of suffering, and assessing and treating physical, psychosocial and spiritual problems".

The intensivist frequently takes a leadership role in end-of-life discussions with patients admitted toward different to ICU, along with their doctors and their nurses (who have a key role in ensuring the continuity of care and goals), and the patients and their families. Other medical teams should be encouraged to take a leadership role in these discussions and to establish early advance care plans (ACP) and its written part (ACD). Discussion about the end of life should not be too fast or carried out with incomplete information.

Attention to these situations is complex. The intensivist must handle the symptoms, and in complicated cases, ask for help to a palliative care specialist. Detailed instructions of withdraw this or that treatment should be made. Care to the family is also difficult is also difficult; unrestricted family visits should be obtained, and if it is possible, an individual room for the patient and his family can be provided. The intensivist who has been involved in the decisionmaking should visit the patient and his family during the process of death of the patient. Religious support should be given when deemed appropriate. When family asks to intensivist if children can say goodbye to their family member, they (children) can be asked, explaining them carefully what they will see.

The Australian and New Zealand Intensive Care Society (ANZICS) describes the principles of end-of-life care [15]. The goal of ICU treatment is to return the patient to a quality of life acceptable for him, and if this is not possible, to compassionately support the death process; suffering must be minimized in all circumstances. All patients receive treatments for therapeutic purposes and symptom relief measures. This balance of treatments varies throughout the critical illness, reaching only measures of symptomatic relief and comfort at the end of life (Graph). The medical team and their patients and families should make a shared decision about treatment options. If there is disagreement, which cannot be resolved with discussion and time, an additional medical opinion or opinions of nondoctors (religious advisors, spiritual counselors, lawyers, etc.) can be sought. All decisions related to the withdrawal or withholding of treatment measures should be included in the medical record, including the reasons for making the decision, who participated, and the treatments to be withdrawn/withheld. The same principles govern the withdrawal and withholding of a treatment, and each ICU and each hospital must develop and implement clinical guidelines according to these principles, promoting the evaluation of end-of-life care as a measure of quality.

The quality of life at the end of life can be defined in several ways. Smith [16] gives us a definition that is based on 12 principles (Table 1):

It is difficult to evaluate the quality of end-of-life care. The main judge on this process, the patient, dies in a high percentage of occasions. The delivery of a long questionnaire to the family can be understood as intrusive by them. Attention may be paid to other indicators that things have been done well: expressions of gratitude from the family at the time of death, other indirect expressions of gratitude (such as financial donations to the hospital), absence of complaints about external interference, etc.


As we have seen before, age should not be an exclusive factor when deciding to enter the ICU. Comorbidities, degree of dependency, chronic diseases in advanced stage, and dementia frequently occur with increasing age should be valued as a whole. Talking and mobility are also factors to be assessed. Baseline quality indicators of the patient, together with specific disease

It is important to assess other failures such as terminal heart failure, respiratory failure with

When it has been decided to move from the goal of intensive to palliative care, efforts must be made to achieve its main objectives. The WHO definition of palliative treatment is [14]: "treatment approach that improves the quality of life of the patient and their families, and maintains the comfort and dignity of the patient, with prevention and alleviation of suffering,

The intensivist frequently takes a leadership role in end-of-life discussions with patients admitted toward different to ICU, along with their doctors and their nurses (who have a key role in ensuring the continuity of care and goals), and the patients and their families. Other medical teams should be encouraged to take a leadership role in these discussions and to establish early advance care plans (ACP) and its written part (ACD). Discussion about the

Attention to these situations is complex. The intensivist must handle the symptoms, and in complicated cases, ask for help to a palliative care specialist. Detailed instructions of withdraw this or that treatment should be made. Care to the family is also difficult is also difficult; unrestricted family visits should be obtained, and if it is possible, an individual room for the patient and his family can be provided. The intensivist who has been involved in the decisionmaking should visit the patient and his family during the process of death of the patient. Religious support should be given when deemed appropriate. When family asks to intensivist if children can say goodbye to their family member, they (children) can be asked, explaining

The Australian and New Zealand Intensive Care Society (ANZICS) describes the principles of end-of-life care [15]. The goal of ICU treatment is to return the patient to a quality of life acceptable for him, and if this is not possible, to compassionately support the death process; suffering must be minimized in all circumstances. All patients receive treatments for therapeutic purposes and symptom relief measures. This balance of treatments varies throughout the critical illness, reaching only measures of symptomatic relief and comfort at the end of life (Graph). The medical team and their patients and families should make a shared decision about treatment options. If there is disagreement, which cannot be resolved with discussion and time, an additional medical opinion or opinions of nondoctors (religious advisors, spiritual counselors, lawyers, etc.) can be sought. All decisions related to the withdrawal or withholding of treatment measures should be included in the medical record, including the reasons for making the decision, who participated, and the treatments to be withdrawn/withheld. The same principles govern the withdrawal and withholding of a treatment, and each ICU and each hospital must develop and implement clinical guidelines according to these principles, promoting the evalua-

markers, may indicate that the patient has started an inexorable path toward death.

home oxygen, renal failure in hemodialysis, or advanced cancer.

and assessing and treating physical, psychosocial and spiritual problems".

end of life should not be too fast or carried out with incomplete information.

them carefully what they will see.

34 Reflections on Bioethics

tion of end-of-life care as a measure of quality.


Table 1. Definition of quality of end of life.

## 6. Consensus building, communication: Documentation

Consensus is an opinion or decision reached by a group as a whole, and it can be followed by all group members even if it is not the preferred option of each individual. This decision of shared decision makes the decision less subject to complaints or legal review than decisions reached by other methods (paternalistic exclusively by the doctor, majority vote, identification of a family member with the right to make any important decision in the patient). This consensus should ideally be achieved between the different medical teams before meeting with the patient, his family, or his decision-making substitute.

The relations between intensivists and other specialists, in order to build a common option, must be constructive.

The discussion must take place at different stages over time, and the meetings must be planned. They must include ICU nurses, social workers, chaplains, and patient families. Communication skills and the proper use of language are very important. Words such as "do everything," "do nothing," "futility," "uselessness" should be avoided, and the "value of treatment options" should be avoided, rather than "the value of the person." The documentation of the decisionmaking process must provide transparency and ensure that the health professional fulfills his professional and legal obligations.

If a patient professes a religion, he may have a fundamentalist or more superficial position. In each case, religion has an impact on decision-making, and the patient's beliefs should be

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It is recommended that a doctor speaks on behalf of the medical teams, since small differences in the explanation of the condition or progress of the patient can be seen as major disagreements in the medical teams. This physician must be experienced and veteran in carrying out these discussions, and he should have achieved the confidence of the patient and his family before discussing the limitation. It should be clarified what the family has heard from previous information; it can happen that what families understand is different from what doctors believe they have said. Additional assurances should also be given, such as that the medical

If patients and their families are involved in decisions, the information on which decisions are based must be accurate. The recognition of the possibility of death allows families to understand the severity of the disease and assesses that prolonging life should not be the only objective. The word "die" should be used if death is a possibility. Sometimes the doctor avoids giving a realistic prognosis to patients and family for the belief that this will keep their hope. The overestimation of the prognosis by the patient or his family can lead to being misinformed,

The reached agreement must be noted in the clinical history. This documentation should provide transparency and responsibility. It should include date and duration of the meeting; people involved in the meeting; medical facts that lead to the decision; written notes about the wishes of the patient, including the ACD/ACP; discussed options, agreed objectives treatment, and agreed consensus; which treatments are going to be withdrawn/withheld and which

• appropriate time for the meeting should be allocated; during it the family must receive nonfragmented information

• ensure that all members of the medical team have a consistent message before the start of the meeting, and that each

• it is necessary to find out what the family has understood up to now of the evolution of the patient; provide new

• show empathy, active listening, and allow silences as a form of respect and compassionate communication;

treatments have to be continued, including medications and symptomatic relief.

• ensure that all important members of the family are present at the meeting before initiating it;

• emphasize continuous patient care when treatments have been limited or not offered;

• update the situation of the patient with recent data, also from other medical teams, before the meeting;

team will remain involved in the treatment and will support the family.

with inappropriate treatment choices.

from the doctor, without interruptions;

member understands their role;

information with simple language;

• encourage asking the family, and answering completely.

Table 2. Important elements to fulfill in a meeting with families of a patient.

The relevant elements of a meeting are listed in Table 2.

• meetings must take place in a private room designated for this purpose;

• the medical team must always have an intensivist and a bed nurse;

explored.

There may be misunderstood cultural themes or linguistic nuances that may introduce small changes of meaning in the discussion. The careful use of translators is recommended. Informal use of untrained interpreters, like other family members, should be avoided, because they may confuse their roles as a translator and as a family member and may misinterpret clinical information.

The determination of what therapeutic options may be clinically indicated and the recommendation of a plan that is the most appropriate considering the wishes of the patient are responsibilities of the intensivist. The intensivist must have leadership in the end-oflife discussions in the ICU and must respect the fact that each patient and each family differ in the discussion process: many families want to have weight in the discussions [17, 18] and described that some families involved in end-of-life decisions may experience long-term psychological harm [19]. It is important that families do not feel an unwanted responsibility or weight associated with these decisions. The careful use of language can limit that feeling of personal responsibility; consensus also serves to share that burden.

Rarely, ICU patients are able to participate in decisions about the end of life. Medication, illness, delirium, dependence, and dementia can alter your ability to make decisions. The formal evaluation of decision-making capacity is important in daily practice and must be applied to the decision to be taken in concrete. The intensivist should assess if the patient is capable of understanding the facts involved in the choices to be made, if he is capable of weighing the consequences, and if he has the ability to communicate his decision.

The agreement with the family is best achieved when they are helped to reach a conclusion by themselves, not when they are confronted with a medical decision previously made. Also when emergency treatment begins with doubts about whether it is appropriate, the family must be informed that a reassessment will occur and that the treatment plan may change.

Understanding the expectations of the decision process is important to avoid misunderstandings. Some patients want their decisions to be made, others prefer to delegate to others (a member of the family), others prefer to delegate to the doctor, etc. There may also be degrees of delegation: full responsibility for the decision process or only specific wishes.

When "devastating damage" occurs in the discussion process, it can be understood that family members want "everything to done," which can include a transfer to a tertiary hospital "with more resources." As a result, you should try to restore trust. The treatment in a tertiary hospital can be carried out by consultation, but not necessarily the patient must move to tertiary hospital, especially if the transfer has no benefit and may pose a risk, or harm, to the patient.

The presence of the social worker and the chaplain in the discussions is recommended, because both can dedicate more time to the family, and because they can be perceived by the family as a more neutral opinion to medical treatment. Also, the presence of cultural leaders is important if there are cultural or tradition issues not fully understood by the doctor.

If a patient professes a religion, he may have a fundamentalist or more superficial position. In each case, religion has an impact on decision-making, and the patient's beliefs should be explored.

It is recommended that a doctor speaks on behalf of the medical teams, since small differences in the explanation of the condition or progress of the patient can be seen as major disagreements in the medical teams. This physician must be experienced and veteran in carrying out these discussions, and he should have achieved the confidence of the patient and his family before discussing the limitation. It should be clarified what the family has heard from previous information; it can happen that what families understand is different from what doctors believe they have said. Additional assurances should also be given, such as that the medical team will remain involved in the treatment and will support the family.

If patients and their families are involved in decisions, the information on which decisions are based must be accurate. The recognition of the possibility of death allows families to understand the severity of the disease and assesses that prolonging life should not be the only objective. The word "die" should be used if death is a possibility. Sometimes the doctor avoids giving a realistic prognosis to patients and family for the belief that this will keep their hope. The overestimation of the prognosis by the patient or his family can lead to being misinformed, with inappropriate treatment choices.

The relevant elements of a meeting are listed in Table 2.

making process must provide transparency and ensure that the health professional fulfills his

There may be misunderstood cultural themes or linguistic nuances that may introduce small changes of meaning in the discussion. The careful use of translators is recommended. Informal use of untrained interpreters, like other family members, should be avoided, because they may confuse their roles as a translator and as a family member and may misinterpret

The determination of what therapeutic options may be clinically indicated and the recommendation of a plan that is the most appropriate considering the wishes of the patient are responsibilities of the intensivist. The intensivist must have leadership in the end-oflife discussions in the ICU and must respect the fact that each patient and each family differ in the discussion process: many families want to have weight in the discussions [17, 18] and described that some families involved in end-of-life decisions may experience long-term psychological harm [19]. It is important that families do not feel an unwanted responsibility or weight associated with these decisions. The careful use of language can limit that feeling of personal responsibility; consensus also serves to share that burden.

Rarely, ICU patients are able to participate in decisions about the end of life. Medication, illness, delirium, dependence, and dementia can alter your ability to make decisions. The formal evaluation of decision-making capacity is important in daily practice and must be applied to the decision to be taken in concrete. The intensivist should assess if the patient is capable of understanding the facts involved in the choices to be made, if he is capable of

The agreement with the family is best achieved when they are helped to reach a conclusion by themselves, not when they are confronted with a medical decision previously made. Also when emergency treatment begins with doubts about whether it is appropriate, the family must be informed that a reassessment will occur and that the treatment plan may

Understanding the expectations of the decision process is important to avoid misunderstandings. Some patients want their decisions to be made, others prefer to delegate to others (a member of the family), others prefer to delegate to the doctor, etc. There may also be degrees of

When "devastating damage" occurs in the discussion process, it can be understood that family members want "everything to done," which can include a transfer to a tertiary hospital "with more resources." As a result, you should try to restore trust. The treatment in a tertiary hospital can be carried out by consultation, but not necessarily the patient must move to tertiary hospital,

The presence of the social worker and the chaplain in the discussions is recommended, because both can dedicate more time to the family, and because they can be perceived by the family as a more neutral opinion to medical treatment. Also, the presence of cultural leaders is important

weighing the consequences, and if he has the ability to communicate his decision.

delegation: full responsibility for the decision process or only specific wishes.

especially if the transfer has no benefit and may pose a risk, or harm, to the patient.

if there are cultural or tradition issues not fully understood by the doctor.

professional and legal obligations.

clinical information.

36 Reflections on Bioethics

change.

The reached agreement must be noted in the clinical history. This documentation should provide transparency and responsibility. It should include date and duration of the meeting; people involved in the meeting; medical facts that lead to the decision; written notes about the wishes of the patient, including the ACD/ACP; discussed options, agreed objectives treatment, and agreed consensus; which treatments are going to be withdrawn/withheld and which treatments have to be continued, including medications and symptomatic relief.


Table 2. Important elements to fulfill in a meeting with families of a patient.
