Palliative Care Ethics: Medicine's Duty to Help

*Sukru Keles*

### **Abstract**

In palliative care, death, which is a part of human nature, is considered as a normal process. This type of care is concerned with the quality of life rather than its duration. In this context, the basic aim is to perform practices to relieve the patient in a way that does not raise any ethical suspicion. Within this framework, it can be said that palliative care is a requirement of medicine's duty to help. The aim of this chapter is to draw attention to the importance of ethical values in the configuration of palliative care services for patients who are in the last period of their life or the ones who have terminal illnesses. In palliative care, it is essential to arrange care services in a manner that does not raise any ethical doubt about the measures taken to increase beneficence both to the patients who are in the last days of their life and to their relatives. In this study, "The Directive for Implementing Procedures of Palliative Care Services" prepared by the Ministry of Health in Turkey in 2015 will be evaluated in terms of ethics.

**Keywords:** bioethics, medical ethics, clinical ethics, palliative care ethics, directive

### **1. Introduction**

Ethics is a branch of medicine that deals with the questions as to the values such as "What's good" or "What's good for people" [1]. Medical ethics is a branch of general ethics which centers on moral issues encountered in the field of health. In this respect, medical ethics is a field where the emerging moral issues, particularly the ones stemming from the medical advances witnessed in the twenty-first century in diagnosis and treatment tools, are discussed.

In health ethics, studies on the evaluation of moral priorities in the field of health and in legal, political, or institutional aspects and the analysis of their possible outcomes have been carried out. Different from medical ethics, health ethics deal with issues that concern a larger majority of the society. Ethical evaluation of health decisions made on a societal level and in accordance with the regulated norms, policies at hand, and supported projects is one of the topics of interests in health ethics.

The right to a healthy life is a fundamental human right. Everyone has the right to receive healthcare, and this right is guaranteed by the constitutions of nations. The right to healthcare is a positive right. Therefore, healthcare providers are expected to create opportunities for the beneficiaries. Besides, configuration of different kinds of health services in healthcare is essential.

There is a close relation between health ethics and the legal regulations for maintaining healthcare services. The significant point in terms of health ethics

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*Palliative Care*

[19] Knaul FM, Farmer PE, Krakauer EL, et al. Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: The Lancet Commission report. Lancet. 2018;**391**:1391-1454. DOI: 10.1016/

[20] Gomes B, Calanzani N, Curiale V, et al. Effectiveness and costeffectiveness of home palliative care services for adults with advanced illness and their caregivers. Cochrane Database of Systematic Reviews. 2013;**2013**(6):CD007760-CD007760. DOI: 10.1002/14651858.CD007760.pub2

S0140-6736(17)32513-8

is that the legal regulations are drawn in an ethically acceptable manner. In this respect, "The Directive for Implementing Procedures of Palliative Care Services" prepared by the Ministry of Health in Turkey in 2015 will be evaluated in terms of ethics in the subsequent sections of the study [2]. With that directive, it was aimed to provide medical, psychological, social, and moral support to both patients and their relatives when life-threatening diseases are at stake. It can be said that the Directive, which comprises basic ethical principles and their extensions, satisfies the expectations of patients and their relatives from palliative care services to a large extent [3].

Given that the organization of palliative care services across the country is a recent trend, it can be envisaged that palliative care will be accepted by healthcare demanders as an accessible and claimable healthcare service in the forthcoming years.

## **2. Palliative care and "confidence" in medicine**

In the literature of medical ethics and philosophy, the necessity to perform certain actions or deeming them as necessary is considered to be a "duty" [1]. The duty of a healthcare professional or a physician is based on carrying out an action that she/he is authorized or allowed to do in an appropriate manner. In established philosophical thinking, at least from Kantian thinking to modern philosophy, the concept of duty in ethics means acting from intention without any compulsion and believing that it is the right thing. As a requirement of social contract, the sense of duty forms the basis of behaving ethically. In this respect, regardless of any legal and juridical imposition, healthcare professionals feel themselves responsible for the practices they perform and act accordingly and provide healthcare services to patients. It is imperative that healthcare professionals carry out their duties in accordance with the medicine's raison d'être in order to maintain the confidence in medicine.

Healthcare professionals are expected to care for patients and be sensitive to their needs. The thing to consider here is paying regard to beneficence to the patient and helping the patient improve his/her current condition. A relationship based on trust between the healthcare professional and the patient or the patient's relatives is a prerequisite to pursue the implementation of healthcare services at the optimum level. Providing healthcare services to anyone who requests it is one of the most fundamental duties of healthcare professionals.

Palliative care is not centered solely on patients; it also covers the practices such as fulfilling the needs of patients' relatives as well. This includes helping the patient's relatives in the mourning days, after the loss of the patient. Palliative care service is carried out by a team, and each step of the process is accompanied by healthcare professionals qualified in their field.

The World Health Organization (WHO) defines palliative care as follows:

"Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual" [4].

The emerging points in the definition of the WHO are:


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*Palliative Care Ethics: Medicine's Duty to Help DOI: http://dx.doi.org/10.5772/intechopen.85160*

i.Letting the patient to die

ii.Assisting the patient to die

regard when she/he had competence.

iii.Speeding up the patient's death

iv.Sustaining the life in an artificial manner

that palliative care is not:

iii.Human is a creature who must be respected; therefore, the quality of death

In societies where the philosophy of palliative care is not fully comprehended, such care practices are frequently confused with other practices. It should be noted

The quality of palliative care is closely related to "confidence" in medicine. In order to provide palliative care to a patient in the last days of his/her life, it's imperative that the patient demands this care at his/her own request and approves of it. The patient should be informed about the purpose of palliative care and the possible benefits of it. It is crucial that the patient has competence to give such a decision and approve of the procedure. Within the context of medical ethics, competence means an individual's ability to make autonomous decisions concerning his/her own health [1]. When a competent individual whose life is coming to an end loses his/her competence, he/she must have unconditional confidence in medicine as to what kind of healthcare he/she will receive. It is disputable how to act in conditions where competence is lost due to the cultural values in different societies. Therefore, the most ethically appropriate act would be taking into account the decision that the patient made when he/she was still competent and assuring the patient in this

**3. Palliative care and the patient's "compelling" medical condition**

sized, and suggestions for resolving ethical problems are debated [7, 8].

Recently, a number of opinions have been generated as to the fact that care services to be provided for life-threatening diseases shall not be limited to medical theories and practices and that the related culture, economy, society, and political environment must also be taken into account [5, 6]. In palliative care, life-threatening diseases are needed to be handled with a holistic approach, and for this reason, a care service performed by a multidisciplinary team is offered to patients and their relatives. In palliative care, ethical values specific to this "challenging" period are empha-

Contemporary palliative care began at the end of the 1950s by means of observing dying patients and providing healthcare services to them. Dr. Cicely Saunders observed dying patients and stated that an interdisciplinary team could be able to alleviate the pain of dying patients and their relatives. Today, providing end-of-life care with a team of healthcare professionals constitutes the core of palliative care services. Dr. Elisabeth Kübler-Ross, who was a psychiatrist in the USA in the 1960s, emphasized in her book *On Death and Dying* the importance of open, respectful, and honest communication with dying patients. In 1974, Dr. Balfour Mount pointed out the importance of a holistic approach in respect of physical, mental, and social aspects to patients who have life-limiting illnesses and their families. In 1997, with the report "Approaching Death: Improving Care at the End of Life," the Institute of Medicine documented the shortcomings related with the end-of-life care and paved

should be equally esteemed as the quality of life.

#### *Palliative Care Ethics: Medicine's Duty to Help DOI: http://dx.doi.org/10.5772/intechopen.85160*

*Palliative Care*

services to a large extent [3].

the confidence in medicine.

fundamental duties of healthcare professionals.

healthcare professionals qualified in their field.

The emerging points in the definition of the WHO are:

**2. Palliative care and "confidence" in medicine**

is that the legal regulations are drawn in an ethically acceptable manner. In this respect, "The Directive for Implementing Procedures of Palliative Care Services" prepared by the Ministry of Health in Turkey in 2015 will be evaluated in terms of ethics in the subsequent sections of the study [2]. With that directive, it was aimed to provide medical, psychological, social, and moral support to both patients and their relatives when life-threatening diseases are at stake. It can be said that the Directive, which comprises basic ethical principles and their extensions, satisfies the expectations of patients and their relatives from palliative care

Given that the organization of palliative care services across the country is a recent trend, it can be envisaged that palliative care will be accepted by healthcare demanders as an accessible and claimable healthcare service in the forthcoming years.

In the literature of medical ethics and philosophy, the necessity to perform certain actions or deeming them as necessary is considered to be a "duty" [1]. The duty of a healthcare professional or a physician is based on carrying out an action that she/he is authorized or allowed to do in an appropriate manner. In established philosophical thinking, at least from Kantian thinking to modern philosophy, the concept of duty in ethics means acting from intention without any compulsion and believing that it is the right thing. As a requirement of social contract, the sense of duty forms the basis of behaving ethically. In this respect, regardless of any legal and juridical imposition, healthcare professionals feel themselves responsible for the practices they perform and act accordingly and provide healthcare services to patients. It is imperative that healthcare professionals carry out their duties in accordance with the medicine's raison d'être in order to maintain

Healthcare professionals are expected to care for patients and be sensitive to their needs. The thing to consider here is paying regard to beneficence to the patient and helping the patient improve his/her current condition. A relationship based on trust between the healthcare professional and the patient or the patient's relatives is a prerequisite to pursue the implementation of healthcare services at the optimum level. Providing healthcare services to anyone who requests it is one of the most

Palliative care is not centered solely on patients; it also covers the practices such as fulfilling the needs of patients' relatives as well. This includes helping the patient's relatives in the mourning days, after the loss of the patient. Palliative care service is carried out by a team, and each step of the process is accompanied by

The World Health Organization (WHO) defines palliative care as follows: "Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial

i.Palliative care ethics focuses on moral problems related with the end of life.

ii.Patient care shall not be defined just with medical procedures; social, cultural, economic, and belief systems are also the important components.

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and spiritual" [4].

iii.Human is a creature who must be respected; therefore, the quality of death should be equally esteemed as the quality of life.

In societies where the philosophy of palliative care is not fully comprehended, such care practices are frequently confused with other practices. It should be noted that palliative care is not:


The quality of palliative care is closely related to "confidence" in medicine. In order to provide palliative care to a patient in the last days of his/her life, it's imperative that the patient demands this care at his/her own request and approves of it. The patient should be informed about the purpose of palliative care and the possible benefits of it. It is crucial that the patient has competence to give such a decision and approve of the procedure. Within the context of medical ethics, competence means an individual's ability to make autonomous decisions concerning his/her own health [1]. When a competent individual whose life is coming to an end loses his/her competence, he/she must have unconditional confidence in medicine as to what kind of healthcare he/she will receive. It is disputable how to act in conditions where competence is lost due to the cultural values in different societies. Therefore, the most ethically appropriate act would be taking into account the decision that the patient made when he/she was still competent and assuring the patient in this regard when she/he had competence.
