Bioethical Considerations of End of Life Care

Bioethical Considerations of End of Life Care
Introduction
Bioethics has influenced the policy relating to end-of-life care with regard to the treatments to administer, amplify, stop, or withhold. It is of specific interest in the attempts to understand the most effective decision-making End-of-life care is characterized by several ethical dilemmas that capture public attention with issues concerning the patients wishes and those of other interests, such as family members.
Ethical dilemma presented
The dilemma presented in end-of-life care relates to consideration of the individuals welfare, interests of family members as well as the community, health caregivers’ interests, and societal interest in allocating the scarce resources.

Ethical principles breached
In the end-of-life care, autonomy is one of the ethical principles significantly influenced by decisions to administer, amplify, stop, or withhold treatments to a patient. Several bioethicists posit that autonomy is a major ethical issue concerning end-of-life decision-making with consideration to various justifications of overruling patients’ autonomy.
Welfare of the individual
At times, the autonomous decisions of patients may seem to compromise their welfare. While an individual may be capable of making decisions, he or she may be incapable of reasoning about their personal impact. Under such circumstances, one might argue that the decisions are inauthenticthey would not serve the persons best interest as that person would have defined it, had he or she been capable of reasoning. Traditional bioethical analysis contends that there is rarely, if ever, any justification for overruling the decisions of people with decision-making capacity. If a decision seems to be uncharacteristic of an individualinconsistent with the persons deeply held values, beliefs, and goalsthen inquiring about the soundness of the persons decision-making capacity is justifiable. But once that soundness is established, often by psychiatric testing, the fact that a decision seems to run counter to the individuals welfare is not an adequate ethical or legal basis for overturning it. If someones decisions could simply be ignored when, in the view of others, they would be harmful to the individuals well-being, autonomy would become meaningless; people would have autonomy only when their decisions comported with some external standard, which is the antithesis of autonomy.
The interests of others
The centrality of autonomy is sometimes criticized for failing to regard the individual as part of a complex network of relationships. According to this view, the interests of the persons partner, children, parents, and others who are close must be taken into account in end-of-life decisions. Decisions that prolong life can entail prolonged suffering for patients and their close family members and friends. Decisions that shorten a patients life also have consequences for others. Aside from the grief of the survivors, such decisions can impose burdensfor example, the need to provide for a child who is still a minor. On the other hand, decisions to shorten a patients life can also have possible benefits, such as the comfort of knowing that a loved one is no longer suffering, or an end to the stress and expense of care giving.
Some bioethicists emphasize the importance of family and community interests in decision-making at the end of life. However, mainstream bioethical analysis rejects them as valid considerations unless the patient chooses to have them taken into account. So does the law. Although judicial decisions usually proclaim that an individuals right of self-determination must be balanced against the states interest in the well-being of the individuals minor children, even that interest has virtually never been found to outweigh the patients right of self-determination.
Interests of health caregivers
Relationships that dying individuals have with their medical and personal caregivers can become quite close and intense. The training, ethos, and codes of ethics of health care professionals buttress the feelings that arise from these relationships. Some people argue that permitting patients to make medical decisions that would shorten their lives could undermine the morale of health care professionals and thus their commitment to doing their utmost for every patient. Seen this way, one patients decision could adversely affect the quality of care not just for that individual, but also for patients in general. The interests of caregivers have been invoked in a few legal cases involving patients decisions to refuse medical treatment, but courts have not ruled that this interest outweighs a patients right of self-determination.
Societal interest in allocation of scarce resources
Medical resources are scarce. That much is uncontroversial. But of all the reasons for overriding patients autonomy, the societal interest in the efficient use of scarce health care resources is the most controversial. Some people believe that an individuals decision to continue medical care at the end of life must be weighed against the cost-benefit ratio. In other words, overriding a patients desire for a particular treatment is justified if the benefits of the treatment come at too high a price, or if there is compelling evidence that the treatment will provide no benefit.
Proponents further contend that it is ethically permissibleindeed, ethically obligatoryto deny resources if they will provide little or no benefit when the cost is being borne in whole or in large part by society: by taxpayers through Medicare, Medicaid, or other government programs, or through private insurance. Opponents of this position acknowledge the scarcity of resources, but claim that such bedside rationing violates the physicians professional obligation to act solely in the patients best interests, and that denial of treatment should be made at the policy, rather than the individual, level.
Another dilemma arises when a doctor thinks that a treatment is not beneficial, but a patient wants it anyway. Despite several dozen state supreme court opinions upholding patients decisions to forgo life-sustaining medical treatment, there has been little discussion about what legal protection, if any, ought to be accorded a patients wish to receive treatment that physicians do not consider worthwhile.
The law is clearer with regard to private health insurance companies and government payers for health care. Standard health insurance contracts, as well as Medicare and Medicaid policies, give these payers the right to refuse coverage for treatment deemed not medically necessary. Many patients have challenged these policies and prevailed, but the underlying principle that health insurance programs may deny payment for treatment of little or no benefit has never been seriously questioned.