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An Ethical Framework for Clinical Decision-Making at the end of Life

Because of advances in medicine, decision-making at the end of life is no longer simple. Public debate on television and articles in journals demonstrate the need for an ethical framework to solve moral dilemmas in caring for the irreversibly ill. This paper proposes three principles that should underpin medical behaviour. During three years' research we set out to determine the practical problems that senior medical staff were facing by interviewing small groups at the Royal Society of Medicine. We invited individuals from anaesthesia, general practice, geriatrics, neurosurgery and neurodisability, oncology, and palliative care. Three participants were chosen because of their published support for euthanasia, advance directives or 'pro-life' campaigns. Later, we involved junior hospital doctors, nursing and therapy staff, general practitioners, pensioners' groups, ethicists and hospital chaplains. Whilst the duty to provide for the care of the sick is incumbent on the whole of society, the knowledge and training of doctors gives them special responsibilities. However, from our research it soon became obvious that among practitioners there is a moral vacuum on this question. This arises because doctors have both to respect human life and to accept the mortality of man. At all levels there was confusion about questions such as 'Who is responsible for death when treatment is withdrawn?' and 'Why is it not necessary always to treat?'. This could be stated simply as problems over the distinction between killing and letting die. However, from the outset it was clear that the problem begins with the difference between two extremes keeping a patient alive at all costs (vitalism) and seeking to bring about death (euthanasia).