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Current controversies in critical care ethics: not just end of life.

Acutely ill and injured patients may require medical management in intensive care units (ICU) where specially trained physicians and nurses can render highly technical care not usually available in the general hospital. The intent of critical care medicine is to reverse or support perturbations in physiology and to save lives. With newer, more technological, and sometimes “aggressive” medical therapies, patients, families, and caregivers are put in a position to make difficult choices. When the critical care is successful (meaning lives are returned to normal), they might perceive critical care medicine to be a “miracle.” On the other hand, unsuccessful or injudicious application of this same technology may help create clinical scenarios in which the patient can be maintained alive only in an ICU setting with burdensome therapy, never to enter a conscious state, and perhaps survive the hospitalization only to be discharged to home with an unacceptable quality of life. Worse, when therapy is failing, the patient’s mere presence in the ICU may deprive another patient who may have a greater chance of a more meaningful survival from gaining access to the ICU and the technology it houses. Our medical system, indeed our society, thirsts for better medical care and even pushes for more attempts to improve our patient care. The world and critical care has changed greatly during the past 30 to 40 yrs. The ICU has grown from a clinical venue for caring for patients so sick for such a long period of time (initially measured in hours or a few days) that a new environment had to be created. Now, not only does the ICU fulfill that clinical need, it also has become a hotbed for research, cost, and yes, more frequent as well as more diverse ethical dilemmas. Indeed, the spectrum of critical care ethics has grown beyond questions like “should we continue or stop life-sustaining treatment?” that troubled clinicians and ethicists in the 1960s and the 1970s. Critical care practice has been forced to accommodate and adjust to varied social, religious, and ethnic values. Do-not-resuscitate orders—once rare in an ICU—are now commonplace. Organ donors and recipients are cared for side by side. Policies for cost containment (triage) are debated and implemented; de facto they impact the ability of patients to ever get to that life-saving environment. Access to, economics (and value) of, and disparity in critical care are raising important questions that critical care providers (bedside caregivers and financial officers alike) must confront daily. Evolving science forces us to examine in greater detail our everyday care. Novel research, indeed the permissibility of such research, is front-page news in the lay press. To try to gauge the range of critical care ethics, we reviewed all the ethics manuscripts (n 173) published in Critical Care Medicine from its inception to the present. While end-of-life care represented the single largest topic area (62, 36%), it nevertheless accounted for a minority of all the articles. Other topic areas include, informed consent, pediatric patient advocacy, resuscitation research, organ donation, futility, ICU resource distribution, and brain death (Fig. 1). Thus, critical care ethics encompasses a broad spectrum of issues that result from our successes, failures, and attempts to improve critical care. The University of Pittsburgh Medical Center convenes an annual Controversies in Medical Ethics conference for ethicists, medical care providers, and the recipients of that care (the lay public). The 11th annual session, in May 2002, was devoted to ethical issues in critical care. Ethicists, philosophers, policy experts, and a diverse group of clinicians spoke and later authored manuscripts encompassing their presentations and the discussions they generated. The purpose of this supplement is to present their reports, and hopefully, the spectrum of critical care ethics.