A 90 year old grandmother of 10 is suffering from a hip fracture and a failing heart. She is in a coma and has not documented her wishes for care with a living will. This is unfortunately a common scenario, and many of us have experienced the trauma of witnessing the sad decline of our loved ones. While some families grieve the sudden loss of relatives, others are faced with a series of difficult ethical decisions shared with the caregivers, other family members, and society as a whole. These are usually about what to do next. Should aggressive treatment be withdrawn? Should alleviation of pain be the top priority? What about the desires of the patient, are they known and respected? The most challenging bioethical problem is dealing with these issues on a societal level, because everyone shares a limited amount of healthcare resources. How are resources allocated, and who controls this process?
During their last chapters of life, many patients live off of technology–breathing machines and feeding tubes are prominent examples. The advancement of medical technology has made it possible to greatly extend the lives of critically ill patients for weeks, months, and even years. This care is costly from a financial standpoint and exerts an emotional strain on all parties involved. In the US, a large percentage of our government spending goes to Medicare and Medicaid, centrally controlled and taxpayer funded [1]. The majority of patients who are elderly and/or critically ill are using these program funds, and a disproportionately high amount of these funds are spent during the final weeks of life [1]. Many patients are unable to express their wishes for care before it’s too late; they are automatically granted costly, end of life care. Unwanted care may be delivered at a great cost to everyone involved–most importantly the patient.
Although there are many different bioethical issues to explore regarding end of life care, the central question concerns the role of the government. Should state and local governments have the power to deny precious healthcare resources to some, and give them to others?
The bioethical principle of nonmaleficence suggests denial of care should never be the answer. And if patients choose to continue life-sustaining care, the principle of autonomy is greatly challenged by failing to provide the requested care. This can be deemed as an act of medical malpractice. Complicating matters further, physicians are bound by an oath to “do no harm” [2]. Withdrawing or denying wanted and needed care greatly challenges these ethical concepts.
Examining the issue from another perspective requires taking a broader look at the problem. Because resources are finite, and sometimes scarce, the above ethical principles are adhered to by attempting to do the most good for the greatest number of people. The cost of keeping our 90 year old grandmother on a breathing machine for a week might provide preventive care for hundreds of poor families at risk of diabetes, heart disease, and other life-threatening illnesses.
Some might argue the principle of beneficence provides the answer [2]. We do good as a society by making a maximal effort to help everyone given our limited resources. In the difficult case of a dying grandmother, we do our best to educate her and her family about end of life issues before her elderly years. As a part of her participation in government-funded care, she is required to document her wishes for her doctors and nurses. This avoids the common problem of prolonged, unwanted care. All families participating in government healthcare programs are offered healthy living incentives and education about end of life care so that difficult decisions are made thoughtfully and carefully before sickness sets in.
In reality, healthcare decisions are deeply personal, emotional, and difficult to make. Attempting a “one size fits all” approach is very challenging given a diverse population with variations of medical circumstances. While the government must provide guidance, ultimately the patients’ families should make these personal decisions with physicians.
References:
Ashish K. Jha, M. D. (2018, July 13). End-of-life care, not end-of-life spending. JAMA Forum Archive. Retrieved October 28, 2021, from https://jamanetwork.com/channels/health-forum/fullarticle/2760146.
Varkey, B. (2020, June 4). Principles of clinical ethics and their application to practice. Medical Principles and Practice. Retrieved October 28, 2021, from https://www.karger.com/Article/FullText/509119.